Smilow Shares with Primary Care: Colorectal Cancer

Transcript

• 00:01I'll go ahead and get
• 00:02us started.
• 00:03Good evening and welcome to
• 00:05Smilo Shares with Primary Care.
• 00:08Smilo Shares with Primary Care
• 00:10is a collaborative
• 00:12lecture series between, our primary
• 00:14care clinicians here at Yale
• 00:16and our SMILO Cancer Care
• 00:19Specialists.
• 00:20I'm Karen Brown, a primary
• 00:21care internist,
• 00:23and I will host this
• 00:24evening's talk with the help
• 00:25of Tracy Battaglia.
• 00:28This series highlights
• 00:30the primary care perspective in
• 00:32cancer care.
• 00:33Our primary care perspective is
• 00:35different.
• 00:36We're constantly providing advice to
• 00:38prevent cancer, testing to screen
• 00:40for cancer,
• 00:41testing for cancer, and fortunately
• 00:44less often finding a new
• 00:45cancer.
• 00:46But when we do, it's
• 00:47stressful and we want to
• 00:49get the handoffs right.
• 00:51And so that is the
• 00:53those are the sorts of
• 00:54topics that we deal with.
• 00:56During this talk, please feel
• 00:58free to enter questions into
• 00:59the Q and A. I'll
• 01:00monitor it and pose questions
• 01:02to our speaker during or
• 01:03at the end of the
• 01:04talk when we try to
• 01:05save time for questions and
• 01:06a bit of an open
• 01:07conversation between our speakers.
• 01:10Tonight's topic is colorectal cancer
• 01:13prevention and screening.
• 01:16We have a terrific
• 01:17panel. I'll start by introducing,
• 01:19Doctor. Piaal Alam.
• 01:23Pial is a board certified
• 01:25family medicine physician.
• 01:27He received his medical degree
• 01:29from the New York Institute
• 01:31Technology
• 01:32College of Osteopathic
• 01:34Medicine and he completed his
• 01:35family medicine residency at Northwell
• 01:38Health.
• 01:39He is a primary care
• 01:41physician,
• 01:42a busy primary care physician,
• 01:44for Northeast Medical Group here
• 01:46at Yale in Rye Brook,
• 01:47New York. In his spare
• 01:49time, he is also an
• 01:50executive Miles per hour candidate
• 01:52at the Yale School of
• 01:53Public Health focusing on health
• 01:55policy.
• 01:56He serves as a co
• 01:58director for another lecture series,
• 02:01called Trust Your Gut on
• 02:02Digestive Health.
• 02:04He's very involved
• 02:05in what we call our
• 02:06care signature pathways,
• 02:08chairing and authoring several ambulatory
• 02:11pathways and sitting on the
• 02:12primary care and infectious disease
• 02:14councils.
• 02:15He also recently joined the
• 02:16Connecticut Department of Health
• 02:18outpatient antibiotic
• 02:20stewardship
• 02:21committee.
• 02:22I'm gonna turn,
• 02:24over,
• 02:25my virtual microphone,
• 02:26to Tracy Battaglia
• 02:28who joins me tonight as
• 02:29a cohost. She's the associate
• 02:31director of the Cancer Care
• 02:33Equity,
• 02:34at our Yale Cancer Center,
• 02:36and and she counts double
• 02:38because she's an internist,
• 02:40and a professor in our
• 02:42section of general internal medicine.
• 02:44And she will introduce our
• 02:45other speakers.
• 02:46Tracy? Thank you, doctor Brown.
• 02:48It's really a pleasure to
• 02:49be here this evening with
• 02:51all of you and to,
• 02:53introduce our esteemed panel. I'm
• 02:54excited to learn from this
• 02:55panel.
• 02:56Let me first, on behalf
• 02:58of the Cancer Center, introduce
• 02:59you to doctor Thayjal Shreekumar.
• 03:02Doctor Shreekumar is an assistant
• 03:03professor of medicine and medical
• 03:05oncology and hematology, where she
• 03:07cares for patients as part
• 03:08of the Center for Gastrointestinal
• 03:10Cancers at Smilow Cancer Hospital
• 03:12and Yale Cancer Center here
• 03:14in New Haven.
• 03:16She completed her undergraduate degree
• 03:18in heart at Harvard
• 03:19and then received her medical
• 03:21degree from the University of
• 03:22Florida College of Medicine and
• 03:24completed her residency
• 03:26here at Yale, where she
• 03:27also served as chief resident.
• 03:29She went on to complete
• 03:30her medical oncology and hematology
• 03:33fellowship and,
• 03:34chief year fellowship here at
• 03:36Yale,
• 03:37which at the time she
• 03:39obtained her executive master of
• 03:41public health degree in epidemiology
• 03:42and health health informatics.
• 03:45We're very fortunate to have
• 03:46doctor Sri Kumar's clinical research
• 03:48efforts here centered around caring
• 03:50for young adults with gastrointestinal
• 03:52malignancies,
• 03:53and she's also quite passionate
• 03:55about medical education as she
• 03:57serves as our assistant program
• 03:58director
• 03:59for the Yale Medical Oncology
• 04:01Hematology Fellowship Program. Thank you
• 04:03for being here, doctor Sreekumar.
• 04:06I'm also here to introduce
• 04:08you to doctor Xavier Lohr,
• 04:11who received his MD
• 04:13degree from the University of
• 04:14Barcelona.
• 04:16Doctor Lohr is trained in
• 04:17basic research and internal medicine
• 04:19at the University of Chicago,
• 04:21where he also completed his
• 04:22GI fellowship
• 04:24at the University of Illinois
• 04:25at Chicago.
• 04:27He complemented his training with
• 04:29a PhD degree in molecular
• 04:30biology from the University of
• 04:32Barcelona.
• 04:33He's a very active clinical
• 04:35gastroenterologist
• 04:36where his research and clinical
• 04:38interests relate to gastrointestinal
• 04:40cancer prevention.
• 04:41He has an active basic
• 04:42science and translational research program,
• 04:45which focuses on several aspects
• 04:47of gastrointestinal
• 04:48cancer,
• 04:49hereditary and familial forms, screening
• 04:51and prevention,
• 04:52and disparities.
• 04:54He is a well published,
• 04:56investigator in the field, making
• 04:58seminal contributions to the fields
• 05:00of Lynch Syndrome and other
• 05:01non polyposis syndromic
• 05:03colorectal cancer cases.
• 05:05He holds many leadership,
• 05:07positions nationally, most notably at
• 05:09the National,
• 05:10Colorectal Cancer Roundtable
• 05:13and, the National Comprehensive Cancer
• 05:15Network. So we're thrilled to
• 05:16have doctor Lohr here
• 05:18as a panelist.
• 05:22I'll pass it off to,
• 05:23our panelists to get us
• 05:25started.
• 05:26Thank you to both Karen
• 05:27and Tracy for those wonderful
• 05:29introductions, and thank you to
• 05:30the entire smile team for
• 05:31hosting us here tonight. And
• 05:33also thank you to our
• 05:34audience for joining us. Before
• 05:36we get started, I'll give
• 05:37a little bit of a
• 05:37background.
• 05:38So with that, colorectal cancer
• 05:41is a relatively common disease.
• 05:42In the United States, over
• 05:44a hundred and fifty four
• 05:45thousand new cases of colon
• 05:47and rectal cancer are diagnosed
• 05:49annually.
• 05:50Colorectal cancer incidence and mortality
• 05:52rates vary markedly around the
• 05:54world.
• 05:55Globally, colorectal cancer is the
• 05:57third most diagnosed cancer in
• 05:59males, and the second most
• 06:00in females, according to the
• 06:02World Health Organization.
• 06:04Tonight, we will go into
• 06:05greater detail about some clinical
• 06:07presentations in the primary care
• 06:09setting,
• 06:10when and how to screen,
• 06:11and what history and red
• 06:12flags to keep an eye
• 06:13out for to best support
• 06:15our patients.
• 06:16Next slide, please.
• 06:18So the United States Preventative
• 06:20Services Task Force recommends that
• 06:23adults age forty five to
• 06:25seventy five be screened for
• 06:26colorectal cancer.
• 06:28Most people should be begin
• 06:30screening for colorectal cancer as
• 06:32soon as after turning forty
• 06:34five, then continue getting screened
• 06:35at regular intervals.
• 06:37However, you may need to
• 06:38be tested earlier than forty
• 06:40five or more often than
• 06:41this in certain, clinical scenarios.
• 06:44Some of which being inflammatory
• 06:46bowel disease,
• 06:48like Crohn's disease or ulcerative
• 06:49colitis,
• 06:50a personal or family history
• 06:52of colorectal cancer, or colorectal
• 06:54polyps,
• 06:55or, genetic syndromes, such as
• 06:57familial adenovitis,
• 06:58paleposis, or hereditary
• 07:01nonpulposis
• 07:02colorectal cancer, Lynch syndrome.
• 07:04And with that, I'd like
• 07:06to hand over to Javier
• 07:07to discuss a little bit
• 07:08more about this.
• 07:09Thank you, Biel. So,
• 07:11starting first with, colorectal cancer
• 07:14screening options. As we've,
• 07:16heard over the last few
• 07:17years, the armamentarium
• 07:19for colorectal cancer screening has
• 07:20grown. And with the growth,
• 07:22complexity has come with that,
• 07:24and, we'll really have to
• 07:26try to figure out what
• 07:27best suits our patients and
• 07:29how we handle that. This
• 07:30is a summary,
• 07:32slide from the NCCN,
• 07:34guidelines on colorectal cancer screening,
• 07:37and that shows, on the
• 07:38left side, you see all
• 07:39the different modalities starting with
• 07:41colonoscopy, which was has been
• 07:43the traditional,
• 07:44screening method in the US,
• 07:46then down the flexible sigmoidoscopy,
• 07:48CT colonography,
• 07:49then FOBT,
• 07:51and then now that mostly
• 07:53have been substituted that, by,
• 07:55FIT
• 07:57and then, multi target stool
• 07:59DNA test, the Cologuard test
• 08:00that and then you can
• 08:02see sensitivity and specificity for
• 08:04both colorectal,
• 08:06cancer and then for advanced
• 08:07lesions.
• 08:09On the data on the,
• 08:10data on the Cologuard, that's
• 08:12gonna be updated soon because
• 08:13Cologuard is releasing a new
• 08:16version of their test with
• 08:17a a mark improved in
• 08:18specificity.
• 08:19So that's gonna make an
• 08:21important difference. And over the
• 08:22last couple of years, we've
• 08:23seen an approval,
• 08:25FDA approval of two new
• 08:27methodologies. One of them is
• 08:28a multi target,
• 08:31stool RNA test,
• 08:33that has similar
• 08:35performance to the newest test
• 08:36of,
• 08:38the multi target stool DNA
• 08:39test,
• 08:41maybe with the caveat that,
• 08:43failure rate is probably a
• 08:44little bit higher and and
• 08:45likely related to the,
• 08:47handling RNA instead of DNA,
• 08:50but, something that, something that,
• 08:54overall didn't seem to have
• 08:56a significant impact. But, again,
• 08:57it's a consideration.
• 08:58And finally, the blood based,
• 09:01cell free DNA test that's
• 09:03come about,
• 09:04again, the last year,
• 09:06with the caveat that the
• 09:08sensitivity is definitely,
• 09:10lower at this point,
• 09:12than the, those, stool tests
• 09:14that we mentioned
• 09:15before.
• 09:16And,
• 09:17and with that,
• 09:19we've we've come a little
• 09:21bit concerned about the fact
• 09:23of,
• 09:24using this more of a
• 09:26generalized
• 09:27way,
• 09:28Particularly, this is going to
• 09:30substitute the other options that
• 09:31probably are better at this
• 09:33point. But, anyways,
• 09:35that's probably gonna get better,
• 09:36and it's gonna be another,
• 09:39important tool that we'll be
• 09:40using for
• 09:41colorectal cancer screening. So stay
• 09:43tuned because this is really
• 09:45a moving target, and there
• 09:46are more tests,
• 09:47coming up. And, hopefully, we'll
• 09:48be able to,
• 09:50altogether,
• 09:51manage the, this new world
• 09:53of different options and and,
• 09:55be able to, like,
• 09:57make sure that, at the
• 09:58end, what we do is
• 09:59screen better and more patients.
• 10:03Hundred percent agree, Shrav here,
• 10:05especially from the primary care
• 10:06side. Being able to advocate
• 10:08for our patients by giving
• 10:09them the options,
• 10:11and being up to date
• 10:12on those guidelines is so
• 10:14important for us. So thank
• 10:15you again for that. And
• 10:17on that note, a nice
• 10:18little segue.
• 10:20So for our health care
• 10:21system, we have something called
• 10:22the care signature pathways. Many
• 10:24of you may be familiar
• 10:25with this.
• 10:26What we do is essentially
• 10:28provide
• 10:29some clinical guidelines and clinical
• 10:31recommendations
• 10:33based off of expert consensus.
• 10:35Speaking of voice, Javier was
• 10:37the one of the chairs
• 10:38for this department.
• 10:40Doctor Karen Brown was also
• 10:41part of this. So it's
• 10:42a collaborative effort between
• 10:44primary care, experts and specialist
• 10:46experts.
• 10:48Multidisciplinary
• 10:49as well. We sometimes have
• 10:51lab or imaging part of
• 10:52the team as well, depending
• 10:53on the pathway.
• 10:55So it's an excellent resource
• 10:57that we have. So with
• 10:58that, would we actually be
• 10:59able to skip forward to,
• 11:01three more slides?
• 11:03Yes. This one right here.
• 11:04So this kind of gives
• 11:05you an impression of what
• 11:07these care pathways entail,
• 11:09essentially giving you
• 11:11guidance where what ages we
• 11:14may want to screen,
• 11:15what
• 11:16red flags to look out
• 11:17for.
• 11:19So it also provides lots
• 11:21of great patient education tools
• 11:22as well. So if we
• 11:24have access to this within
• 11:25our health care system, I
• 11:26would,
• 11:27recommend our colleagues to please
• 11:29take a look and and
• 11:30give consideration.
• 11:31Okay? Thank you. So with
• 11:34that, we'll go on to
• 11:35our case based discussion of
• 11:37some,
• 11:38colorectal,
• 11:40cancer scenarios.
• 11:41And this first case will
• 11:43be,
• 11:44based off of a real
• 11:45patient with slight modifications for
• 11:47teaching purposes.
• 11:49So this one, I'll read
• 11:50it, Is a fifty seven
• 11:52year old male with a
• 11:53past medical history of hyperlipidemia.
• 11:55It's diet controlled,
• 11:56prediabetes,
• 11:57gout, skin tags, and external
• 11:59hemorrhoids, was presenting to establish
• 12:01care with an annual physical
• 12:03after
• 12:04prior the prior PCP had
• 12:05left the practice. It has
• 12:07been over eighteen months since
• 12:08the last examination.
• 12:10On chart review, during prior
• 12:12visit, patient had complained about
• 12:14blood in the toilet bowl
• 12:15and flares of hemorrhoids.
• 12:17During today's visit,
• 12:18the, this chief complaint still
• 12:21persists.
• 12:22Otherwise, patient is feeling at
• 12:23baseline and at relatively good
• 12:25health.
• 12:26Active,
• 12:27problems include hemorrhoids.
• 12:29Medication wise, nothing,
• 12:31too outstanding,
• 12:32colase, PRN for constipation, vitamin
• 12:35d, vitamin b twelve, and
• 12:36a multivitamin.
• 12:38Social history,
• 12:40the patient is a former
• 12:41smoker, did quit around fourteen
• 12:43years ago, but does have
• 12:44a ten pack year history.
• 12:46Habits wise, social drinking, only
• 12:48about one to two shots
• 12:49of liquor per week.
• 12:51Occupation,
• 12:52no occupational hazard, really. Professional
• 12:54poker poker player.
• 12:56And, no known family history.
• 12:59Next slide, please.
• 13:00So the patient also patient
• 13:03only had a Cologuard done
• 13:05three years ago
• 13:06at this time and and
• 13:08also it was found to
• 13:09be negative at that time.
• 13:10However, patient has never had
• 13:12a colon formal colonoscopy.
• 13:14Patient had received a rectal
• 13:16exam during prior visit with
• 13:17the PCP.
• 13:18Stool guaiac was negative.
• 13:20Therefore, patient had declined a
• 13:22rectal exam on today's visit
• 13:24and wants hemorrhoid cream only.
• 13:27Patient is very apprehensive to
• 13:28colonoscopy
• 13:29and declines,
• 13:31and reluctant for, Cologuard again
• 13:34as it was already negative.
• 13:36So next slide, please.
• 13:38So I guess
• 13:39there's a few of these
• 13:40questions that we'll discuss with,
• 13:42our experts colleagues.
• 13:45This is a patient that
• 13:46I had actually encountered. So
• 13:47and we,
• 13:49as primary care clinicians, may
• 13:51have patients that are reluctant
• 13:53to screening,
• 13:54especially if
• 13:56one
• 13:57it was negative.
• 13:59You know, there's some health
• 14:01literacy concerns as well, I
• 14:03remember with this patient. So
• 14:04let's start answering these questions
• 14:06and get some, guidance from
• 14:07our, experts.
• 14:08So one question we ask
• 14:10as a primary care clinician,
• 14:11what are the next steps?
• 14:13So, Shavir, what would you
• 14:14say there?
• 14:15Sure. So I think the
• 14:16clear
• 14:17message here is when we
• 14:20have heard from our patient
• 14:21that there was a red
• 14:22blood per rectum,
• 14:24we are no longer in
• 14:25the screening realm. And so
• 14:26forget about doing more fit
• 14:28test or other things. And
• 14:29I've just seen a patient
• 14:30today who's has been describing
• 14:32just today in my clinic,
• 14:34which is describing brachycardia
• 14:36for a year, and the
• 14:37PCP did order a,
• 14:39fit test. And it's like,
• 14:41what's the purpose? We have
• 14:43gross blood. We then need
• 14:44to look for a cold
• 14:45blood. We already know. So
• 14:47that takes us to a
• 14:48different level that takes us
• 14:49to a diagnostic level. So
• 14:51forget about anything that applies
• 14:53to screening that's no longer
• 14:54applied to this patient, basically.
• 14:57In terms of the, what
• 14:58the,
• 15:00if it was appropriate for
• 15:01the patient to be screened
• 15:02with Cologuard, that was three
• 15:04years ago. So he would
• 15:05be for
• 15:06do for next one because
• 15:08it's been approved after three
• 15:09years. So at that time,
• 15:10the patient had no family
• 15:11history of colorectal cancer.
• 15:14And, therefore, if there's no
• 15:16family history of colorectal cancer,
• 15:18all these options, all guidelines
• 15:19seem to agree that all
• 15:20these options are reasonable including
• 15:22the cologuard every three years.
• 15:24Now,
• 15:25the patient is a smoker,
• 15:27and and he's a professional,
• 15:29player, so he may actually
• 15:31smoke them more than what
• 15:32we think, actually.
• 15:34So and that increases risk.
• 15:36Clearly,
• 15:36alcohol deaths, obesity, lack of
• 15:38physical exercise, those do increase
• 15:40risk, and and, and we
• 15:42may have some here. The
• 15:43issue, though, is that,
• 15:45in the guidelines, we really
• 15:46have not separated that increased
• 15:48risk from family history risk.
• 15:51So family history calls for
• 15:52colonoscopy.
• 15:54No no family history or
• 15:56other factors,
• 15:57would call for either one
• 15:58of these options, but,
• 16:00I think in the future,
• 16:01we may have to think
• 16:02about how, these factors that
• 16:04we're mentioning here do change
• 16:06the risk and how do
• 16:06we incorporate them in our,
• 16:08decision making about what we
• 16:10suggest,
• 16:11potentially for screening. But, again,
• 16:12we are beyond screening at
• 16:14this point, but we're just
• 16:15talking about the,
• 16:16and,
• 16:18the treatment of the hemorrhoid.
• 16:19At this point, what we
• 16:20really have to do is
• 16:21just look what's going on.
• 16:22And if there are hemorrhoids,
• 16:24we'll treat the hemorrhoids, but
• 16:25first we need to figure
• 16:26out what's going on.
• 16:27Absolutely. And I I love
• 16:29everything that you said. And
• 16:30one of the most take
• 16:31home points there is we've
• 16:32gone from the realm of
• 16:34screening to diagnostic now, and
• 16:35being able to,
• 16:37communicate that, especially
• 16:39with, kindness and grace, especially
• 16:41to a patient that may
• 16:42be a little more reserved
• 16:43and hesitant to,
• 16:45any type of procedure in
• 16:46the first place is very
• 16:48important. So I love everything
• 16:49that she says there. Thank
• 16:51you.
• 16:52And then with that, would
• 16:53we be able to go
• 16:53to the next slide, please?
• 16:55Thank you. And so what
• 16:56happened next? This patient was
• 16:58referred to colorectal surgeon.
• 17:01At this visit, the patient
• 17:02had a rectal exam, which
• 17:03demonstrated an ulcerating rectal mass
• 17:06that extended from the dentate
• 17:07line to eight centimeters above
• 17:09the anal verge.
• 17:11Arrangements were made immediately to
• 17:13have the patient have an
• 17:14urgent colonoscopy.
• 17:16As expected, the biopsy was
• 17:18consistent with,
• 17:19invasive adenocarcinoma.
• 17:22And with that, we'd like
• 17:23to set,
• 17:24give this next slide over
• 17:25to Tejal, please.
• 17:27Thank you so much. So
• 17:28I know this talk is
• 17:30focusing more on colorectal cancer
• 17:33screening and prevention, but I
• 17:35thought it would be helpful
• 17:36to do a big picture
• 17:38overview of what happens
• 17:40when that cancer diagnosis
• 17:42confirmed.
• 17:43So I the first thing
• 17:45that we always want to
• 17:46know is what is the
• 17:48stage of the cancer?
• 17:50The staging of colorectal cancer
• 17:53is done by the American
• 17:56Joint Committee on Cancer, the
• 17:58AJCC
• 17:59based recommendations,
• 18:01which is on the TNM
• 18:03staging system.
• 18:05The T stands for tumor
• 18:07or the depth of invasion
• 18:09into the wall of the
• 18:11colon or the rectum.
• 18:13N stands for lymph nodes
• 18:15or the number of lymph
• 18:16nodes that are involved local
• 18:18regionally.
• 18:19And M stands for metastasis.
• 18:22Whether or not there's any
• 18:23distant sites of disease involvement,
• 18:25for example, in the lung
• 18:27or the liver.
• 18:28And by combining three these
• 18:30three components, we come up
• 18:32with a stage from one
• 18:33to four,
• 18:34one being the the lowest
• 18:36stage and four being the
• 18:38most aggressive, the highest stage.
• 18:41Staging not only helps us
• 18:43determine how aggressive the cancer
• 18:45is, but it really does
• 18:46guide what our treatment options
• 18:49are.
• 18:50Now I should say that,
• 18:52this is our
• 18:54staging system, as of, June
• 18:56third,
• 18:57of twenty twenty five. But
• 18:59just this past weekend,
• 19:00we had our major oncology
• 19:02conference,
• 19:04and there are some new
• 19:06proposed changes
• 19:08to this staging system,
• 19:09which might incorporate other elements
• 19:11such as,
• 19:12tumor deposits and
• 19:14other factors of the biology,
• 19:16which may help us better
• 19:17predict how our patients will
• 19:19do based on their stage.
• 19:21But at this moment in
• 19:22time, this is what we
• 19:23use for our staging.
• 19:26Now when someone has that
• 19:28confirmation
• 19:29of cancer
• 19:30on the biopsy,
• 19:32there are a few more
• 19:32pieces of information that we
• 19:34need
• 19:35to determine all of that
• 19:36staging information
• 19:38and also to help us
• 19:39guide what the next steps
• 19:40are.
• 19:41From the colonoscopy,
• 19:43that bio but that biopsy
• 19:45will confirm the pathology, but
• 19:47we actually send more testing
• 19:50from that pathology
• 19:51to characterize
• 19:53something that we call mismatch
• 19:55repair proteins.
• 19:56And I put an asterisk
• 19:57there because I wanna come
• 19:59back to that. I'll put
• 19:59a pin in it and
• 20:00I'll come back to that.
• 20:01But that can actually have
• 20:02a lot of prognostic and
• 20:04treatment implications for our patients.
• 20:07In addition to the colonoscopy,
• 20:09we get CT scans of
• 20:11the chest, the abdomen and
• 20:12the pelvis to evaluate for
• 20:14distant disease.
• 20:15And we get labs including
• 20:17not only your, basic labs,
• 20:19which is the complete blood
• 20:21count and the comprehensive metabolic
• 20:22panel,
• 20:23but we also will send
• 20:25what we call a CEA,
• 20:26which is a tumor marker
• 20:28or, also known as, carcinoembryonic
• 20:31antigen, which is a protein
• 20:32that the cancer cells make
• 20:34and give us a sense
• 20:35of what the activity might
• 20:36be from the cancer.
• 20:38Now for
• 20:40rectal cancer specifically,
• 20:43we also want to get
• 20:44an MRI of the pelvis.
• 20:47So if you think that
• 20:48the patient just has a
• 20:49colon cancer, meaning,
• 20:51you know, from the cecum
• 20:53through the sigmoid or rectosigmoid,
• 20:55colonoscopy,
• 20:56CT scans in the labs
• 20:58should be sufficient.
• 21:00But this is a key
• 21:01point. We treat rectal cancer
• 21:04differently than how we treat
• 21:06colon cancer, and we need
• 21:07more information. So these were
• 21:09for these patients, we get
• 21:10the MRI, and I'll circle
• 21:11back to that too.
• 21:12I just wanna make a
• 21:13note that we don't typically
• 21:15or routinely get PET scans
• 21:17on our patients unless there's
• 21:19something concerning from our CT
• 21:21scan that would prompt us
• 21:22to do so.
• 21:23From getting all of this
• 21:24information,
• 21:25we wanna answer two main
• 21:27questions.
• 21:28Number one, is this a
• 21:30localized
• 21:31disease, or is it metastatic?
• 21:33And number two, is it
• 21:35colon, or is it rectal?
• 21:37We'll return to our case
• 21:38now to get some of
• 21:39those pieces of information,
• 21:41and then we'll circle back
• 21:43to what happens next. Next.
• 21:45Excellent. And I really love
• 21:46your, two main questions,
• 21:48because that's really the two
• 21:49main questions that a a
• 21:50lot of our patients ask
• 21:51us. Right?
• 21:53Most patients know,
• 21:54the term terminology metastatic now,
• 21:56so they really want to
• 21:57know, is it local or
• 21:59is it
• 21:59metastatic versus,
• 22:01the clinical pearl that you
• 22:02pointed towards, the colon versus
• 22:04rectal from our clinical perspective?
• 22:06That's important for us to
• 22:07know as well.
• 22:08So going back to our
• 22:09case again,
• 22:11the staging,
• 22:12CAT scan,
• 22:13showed no evidence of of
• 22:15distant metastasis for this patient.
• 22:18Rectal MRI,
• 22:19suggested tumor was t three
• 22:21or possibly t four rectal
• 22:23tumor
• 22:24with a suspicious
• 22:25mesorectal
• 22:26lymph node.
• 22:28The tumor also appeared to
• 22:29be extending to the anal
• 22:31sphincter.
• 22:32Clinically, he was staged at
• 22:34t three four, and one.
• 22:37PET scan showed, no distant
• 22:39metastasis.
• 22:40Next slide, please.
• 22:42Thank you. Yeah. So before
• 22:44I go on to the
• 22:45next slide, I'll I'll just
• 22:46make a note here. So,
• 22:48as you as I had
• 22:50mentioned, so we looked at
• 22:51the t stage and the
• 22:52n stage here.
• 22:54So with the t stage,
• 22:55it goes from one to
• 22:57four in terms of the
• 22:58depth of invasion. So
• 23:00having both the deeper invasion
• 23:02as as well as nodal
• 23:03involvement
• 23:04means that he's what we
• 23:06call locally advanced. There's no
• 23:08distant disease, but it's also
• 23:09not necessarily the smallest tumor
• 23:12either. He's kind of in
• 23:13that middle road.
• 23:15So
• 23:16in terms of his next
• 23:18steps in treatment,
• 23:20as I mentioned, we treat
• 23:21colon cancer different than how
• 23:23we treat rectal cancer.
• 23:25And to give you a
• 23:26big picture overview,
• 23:29when someone has a nonmetastatic
• 23:31colon cancer, typically, the standard
• 23:33of care is to
• 23:35take them for surgical resection
• 23:36upfront. And then depending on
• 23:39the final stage and the
• 23:41features of the pathology from
• 23:43the surgical resections specimen,
• 23:45that will help us determine
• 23:47whether or not they need
• 23:48any more treatment after the
• 23:49surgery such as chemotherapy.
• 23:52In contrast,
• 23:54for rectal cancer,
• 23:56we've actually moved a lot
• 23:57of that other treatment upfront
• 24:00before surgery,
• 24:02and we call that treatment
• 24:03strategy total neoadjuvant
• 24:06therapy or TNT.
• 24:09The more recent studies have
• 24:10shown that doing both chemotherapy
• 24:13and
• 24:14chemo radiation
• 24:16before surgery
• 24:17can actually not only decrease
• 24:19the shrink of shrink the
• 24:21tumor and decrease the size
• 24:22of it before the surgery
• 24:24to help
• 24:25decrease the morbidity of a
• 24:27sir a surgery,
• 24:28and, you know, decrease the
• 24:30chances of needing
• 24:31something like a permanent ostomy.
• 24:33But moving all of this
• 24:34treatment upfront has actually also
• 24:36shown to have a benefit
• 24:37for overall survival.
• 24:40So typically, these patients will
• 24:42have
• 24:42chemotherapy, chemo radiation, and then
• 24:45go to surgery.
• 24:46But what we're also finding
• 24:48is that
• 24:49we might actually be curing
• 24:52some of these patients with
• 24:53chemotherapy and chemo radiation alone.
• 24:56This is a small subset
• 24:57of patients, and we're still
• 24:58trying to figure out who
• 24:59that is,
• 25:00but we are doing a
• 25:01lot of work in studying
• 25:03the watch and wait strategy.
• 25:04So treating with chemo and
• 25:06chemo radiation,
• 25:08and then
• 25:09delaying surgery and just following
• 25:11with scans and scopes very
• 25:13closely to see whether or
• 25:15not there's a recurrence of
• 25:16this disease.
• 25:17So let's circle back with
• 25:18our patient and see what
• 25:19happened with him. So our
• 25:21patient did begin this total
• 25:23neoadjuvant therapy or TNT
• 25:26strategy
• 25:27starting with chemoradiation,
• 25:29meaning that while he was
• 25:31getting
• 25:32radiation doses, he was also
• 25:34taking a chemotherapy
• 25:35pill called Xeloda.
• 25:37When he finished the radiation,
• 25:38they got some scans, which
• 25:40showed that he had a
• 25:41good response,
• 25:42and they moved to that
• 25:44next part of the TNT
• 25:45strategy, which is the chemotherapy.
• 25:48He received our standard chemotherapy
• 25:50regimen, which is called FOLFOX,
• 25:52and I won't get into
• 25:53more details about that right
• 25:54now.
• 25:55But after completing
• 25:57both of those components,
• 25:59his PET scans show that
• 26:00he had no residual disease.
• 26:02He got MRIs
• 26:04as well, and this continued
• 26:06to show that he had
• 26:07a com an excellent response
• 26:09to the TNT.
• 26:10And based on discussing with
• 26:12the oncologists and the colorectal
• 26:14surgeons,
• 26:15they decided to proceed with
• 26:16this wash and wait strategy,
• 26:19with, proceeding without surgery and
• 26:21having close surveillance.
• 26:23So first, as of right
• 26:24now, surveillance,
• 26:26for colorectal cancer upon,
• 26:28completing
• 26:29curative intent treatment
• 26:31is following for five years
• 26:34with,
• 26:35physical exams and HMPs as
• 26:37well as labs, imaging, and
• 26:39endoscopies
• 26:40as well.
• 26:43There's just one more point
• 26:44that I wanna make, and
• 26:45this is going back to
• 26:46the asterisk that I had
• 26:47discussed about earlier.
• 26:49And that's about the role
• 26:50of immunotherapy
• 26:52in localized
• 26:53and locally advanced rectal cancer.
• 26:56So you might've seen these,
• 26:58major articles come out in
• 27:00the New York Times and
• 27:01other new sources,
• 27:04showing some dramatic responses that
• 27:05we've seen for a subset
• 27:06of responses that we've seen
• 27:08for a subset
• 27:10of patients who have rectal
• 27:11cancer that are deficient in
• 27:14what we call mismatch repair
• 27:15proteins.
• 27:17This means that they have
• 27:18more DNA damage in their
• 27:20cancers,
• 27:21and therefore, they might be
• 27:23more likely to respond to
• 27:25an immunotherapy
• 27:27based,
• 27:28approach.
• 27:29And there was this really
• 27:31remarkable trial that came out
• 27:33that showed that of the
• 27:35forty nine patients who had
• 27:36rectal cancer with this mismatch
• 27:38repair protein deficiency,
• 27:41they all had a clinical
• 27:42complete response to the immunotherapy
• 27:45alone, and that is without
• 27:46having any chemotherapy,
• 27:49any radiation,
• 27:50or any,
• 27:51surgery on, to remove their
• 27:53initial rectal cancer tumor.
• 27:55So I think that this
• 27:57has been a really exciting
• 27:58finding and is just a
• 28:00a taste of what's next
• 28:01to come. But this comes
• 28:03back to the fact that
• 28:04on our initial diagnosis
• 28:07of rectal cancer,
• 28:08we want to get that
• 28:09information to know whether or
• 28:11not they might be a
• 28:12candidate for immunotherapy.
• 28:16Excellent points, Dejal, and thank
• 28:17you so much. And just
• 28:19to gently wrap up this
• 28:20case,
• 28:21some key points again,
• 28:23do not dismiss mild rectal
• 28:25bleeding, needs, close follow-up. Again,
• 28:27this is where we're transitioning
• 28:29from just screening to diagnostic.
• 28:30Right?
• 28:32Ensure patients are screened at
• 28:33adequate intervals.
• 28:35Thankfully, this patient was. But,
• 28:37again, we need to change
• 28:38our modality to diagnostic.
• 28:41Collaborate with our specialist colleagues
• 28:43if there are suspicious findings
• 28:44or history,
• 28:45and early detection of colorectal
• 28:47cancer is key for treatment
• 28:49options and survival.
• 28:50Okay.
• 28:51And with that, we'll move
• 28:53on to our next case,
• 28:54please.
• 28:55So case two will be,
• 28:58based more so on a
• 28:59suspicious family history.
• 29:01So here we have a
• 29:02twenty five year old female,
• 29:04well, with no significant past
• 29:05medical history, except mild GERD,
• 29:08controlled,
• 29:09presents for a routine physical
• 29:10appointment.
• 29:12As far as active problems,
• 29:14none.
• 29:14Medication wise, PPI, PRN,
• 29:17no social history, no habits,
• 29:20smoking or
• 29:22alcohol
• 29:23occupational wise, teacher.
• 29:25But, we do see there's
• 29:26a family history of multiple
• 29:28colonic polyps in mother diagnosed
• 29:30at age forty.
• 29:33So at this point,
• 29:35some questions, if we could
• 29:36go to the next slide,
• 29:37please, is,
• 29:39what what are some outstanding
• 29:41parts from our history that
• 29:42are standing out to us?
• 29:43So, Shavir, I'd like to
• 29:44hand off to you for
• 29:45this, please. Yeah. I think
• 29:47the first, thing they would
• 29:48like to say is that
• 29:49we, gastroenterology,
• 29:50should be a better job
• 29:51many times at saying,
• 29:54polyps and how many polyps
• 29:55we find. We often
• 29:57describe multiple, and multiple for
• 29:59everyone, it mean may mean
• 30:00a different number. So really,
• 30:02it's not the same to
• 30:03have seen, seven polyps, which
• 30:05for someone can be multiple
• 30:07over the years versus,
• 30:09twenty five polyps.
• 30:11So we really have to
• 30:12be much more specific.
• 30:14It'll be important because the
• 30:16our patient really has not
• 30:17had anything. It's all based
• 30:18on family history. It'll be
• 30:19important to know that did
• 30:20mom have also colorectal cancer,
• 30:22just polyps, how many and
• 30:23all that? Did she have
• 30:25genetic testing?
• 30:26And,
• 30:27key quick key key questions
• 30:29is, again, is like how
• 30:30many polyps, what type of
• 30:31polyps, whether some of them
• 30:33advanced was the patient young
• 30:35at, or mother, young at
• 30:37diagnosis of, those polyps. And,
• 30:39again, did she have genetic
• 30:40testing? Really,
• 30:42getting information from mom may
• 30:44be very, very important on
• 30:45how we address
• 30:48next steps for this patient.
• 30:52If we're looking at, someone
• 30:53who's developed at least ten,
• 30:55fifteen,
• 30:56adenomas or other types of
• 30:58polyps, then we really have
• 31:00to, rule out a hereditary
• 31:01condition. Now we we have
• 31:04a a a list of
• 31:05genes that have been associated
• 31:06and beyond,
• 31:08the the very first one
• 31:09described, like, which was APC.
• 31:12Now we have a variety
• 31:13of them, and some of
• 31:14them,
• 31:15are inherited in an autosomal
• 31:16recessive manner. So you do
• 31:18need two copies of,
• 31:20mutated gene, and and in
• 31:21that case, mom and dad
• 31:22usually won't have polyposis and
• 31:24cancer. So it may seem
• 31:26like it skipped generations. So
• 31:28important that, yeah, we're not
• 31:30we may not,
• 31:31we may have these
• 31:32situations with,
• 31:34with,
• 31:35the generation just above having
• 31:37no polyposis, no colorectal cancer
• 31:40history at all. So, again,
• 31:41we do have,
• 31:43many more,
• 31:44situations that are not the
• 31:45typical,
• 31:47one that are associated with
• 31:48an autosomal dominant pattern. And,
• 31:50also, there are, some de
• 31:51novo mutations in APC up
• 31:53to twenty five percent. So
• 31:55may have no family history
• 31:56at all, and all of
• 31:57a sudden, here we have
• 31:58a new polyposis case. If
• 32:00we can move on to
• 32:01next one,
• 32:03besides those genetic ones, and
• 32:04I would skip the CPU
• 32:06one, we can,
• 32:07with, it's important also to,
• 32:10notice about the
• 32:12potential prior history of
• 32:14chemotherapy and or radiation therapy,
• 32:17particularly during childhood and young
• 32:19adulthood, and that's been, associated
• 32:21with what we call therapy
• 32:22associated polyposis, which often is
• 32:24a, kind of mixed pattern
• 32:26of adenomas and serrated polyps.
• 32:28So important to ask for
• 32:29that information.
• 32:31Next one is serrated polyposis
• 32:32syndrome. Most of the time,
• 32:34not,
• 32:35associated with known,
• 32:38genetic conditions, and this is
• 32:40more, based on clinical
• 32:42criteria.
• 32:43But it does have implications
• 32:44in terms of cancer risk
• 32:46for the patients, but also
• 32:47so for first degree family
• 32:49members. So it's important that
• 32:50we understand what types of
• 32:51polyps there are and make
• 32:53sure, is it a serrated
• 32:54polyposis or not. And going
• 32:56back to the,
• 32:57first scenario, CPOE, that's that's,
• 33:00colonic polyposis of known etiology,
• 33:02and we call those once
• 33:04we've really seen
• 33:06an individual with polyposis with
• 33:07really no evidence of, any
• 33:10genetic mutations in the genes
• 33:12that are commonly associated with
• 33:13polyposis and colorectal cancer. In
• 33:15all those cases too, family
• 33:17members
• 33:18do have a higher risk.
• 33:19So it is important that
• 33:20we kind of, label these
• 33:22cases as appropriate as possible
• 33:24because it does have implications
• 33:26not only for our patients
• 33:27but for family members. So
• 33:28important to gather all that
• 33:29information if we know, if
• 33:31we,
• 33:32want to understand better how
• 33:33to address the, the patient
• 33:35that we're talking about.
• 33:38And and, very, very important,
• 33:40and I think that skips
• 33:41so many of us,
• 33:43which is that
• 33:45even if there are not
• 33:46that many polyps, but if
• 33:47there was an advanced polyp.
• 33:48And how we what we
• 33:50call advanced is, having an
• 33:51adenoma that's
• 33:53larger than one centimeter,
• 33:54adenoma with high grade dysplasia
• 33:56or villous bill tubular adenoma,
• 34:01traditional serrated,
• 34:02adenoma, or advanced sal serrated
• 34:04polyps. All those ones, just
• 34:06having a first degree relative
• 34:08who has had at least
• 34:09one of those put it
• 34:11as a higher risk, and,
• 34:12actually, guidelines are calling for
• 34:14starting colorectal cancer screening at
• 34:16an earlier age,
• 34:17age forty, or whenever the
• 34:18diagnosis was made in that
• 34:20family member. So that's
• 34:22how important it is that
• 34:23we know even if our
• 34:24family member has had just
• 34:26two polyps and is like,
• 34:27okay. Well, big deal. Well,
• 34:28no actually can have implications
• 34:30on how we approach screening
• 34:32for our family members. So
• 34:34very, very important, number one,
• 34:35as physicians to provide that
• 34:37information to our patients
• 34:39and and make them understand
• 34:40that that has implications for,
• 34:42for their,
• 34:44relatives.
• 34:48Ben, thank you so much,
• 34:49Javier. As you're saying that,
• 34:51you know, I was writing
• 34:52down notes as well. I
• 34:53feel like such an important
• 34:55key clinical pearl that you
• 34:56shared right there was not
• 34:57to miss those high risk
• 34:59polyps.
• 35:00Again,
• 35:01we're seeing, colorectal cancer and
• 35:03polyps much earlier,
• 35:06in younger
• 35:07patients. So,
• 35:09not dismissing just polyps in
• 35:10the family,
• 35:11is very important. So in
• 35:12this case,
• 35:14getting a lot more history
• 35:15from the patient if they
• 35:17can share it, like,
• 35:20it would be so, vital
• 35:21and important.
• 35:22And then from the primary
• 35:24care side, I guess what
• 35:26I would want to ask
• 35:27our specialist colleagues is,
• 35:29how would we want to
• 35:30go about
• 35:31managing this patient? Like, after
• 35:33we get, like, a more
• 35:34thorough history,
• 35:35would
• 35:36we refer them to our
• 35:37GI colleagues or want to
• 35:39touch base and coordinate with
• 35:40our, genetic colleagues?
• 35:42Where would you recommend?
• 35:45Yeah. I think definitely when
• 35:47we get that information
• 35:48from, from mom, that would
• 35:50really help us understand.
• 35:52If we do have a
• 35:53suspicion that mom can have
• 35:54a genetic syndrome,
• 35:56the appropriate thing would be,
• 35:58seeing if mom could actually
• 35:59have that, assessment because she's
• 36:02that.
• 36:03I I think that'd be
• 36:04number one. If what, if
• 36:06at the end what we
• 36:06have is, mom had several
• 36:08polyps, none of them advanced
• 36:10or whatever, we can take
• 36:11another approach.
• 36:13And, and,
• 36:14so really, having that information
• 36:16will make a difference. And,
• 36:18again, if we do think
• 36:19it's,
• 36:20it could be genetic as
• 36:21need, to be ruled out
• 36:23that case, always try to
• 36:24get mom,
• 36:26because, you know, she's the
• 36:27affected one. If there's no
• 36:29possibility, then we could definitely
• 36:31test her. And nowadays, panel
• 36:32testing allows for testing all
• 36:34all the genes that we
• 36:35were showing here
• 36:36at a with a single
• 36:38test, so something that's relatively
• 36:40easy to do.
• 36:41Absolutely. We oftentimes,
• 36:43get partial history and fragmented
• 36:45history sometimes, and we may
• 36:47end up having to test
• 36:48our,
• 36:49actual patients. Thank you again
• 36:51for your clinical insights.
• 36:53With that, I think we'll
• 36:54move on to case number
• 36:56three.
• 36:57And
• 36:58with that, this one will
• 36:59be more so an early
• 37:01onset colorectal
• 37:02cancer. So I'll read this
• 37:04as well.
• 37:05We have a thirty nine
• 37:06year old female with no
• 37:07significant past medical history except
• 37:09iron deficiency anemia
• 37:11and IBS who presents to
• 37:12her PCP for a routine
• 37:14physical appointment.
• 37:16Active problems wise, she has
• 37:18iron deficiency anemia,
• 37:20menorrhagia,
• 37:20and IBS. Medication wise,
• 37:23takes an iron supplement,
• 37:24oral contraceptive pill.
• 37:26Social history wise, she's a
• 37:28single mother of two, young
• 37:30children.
• 37:31Habits wise, never a smoker,
• 37:32denies alcohol as well.
• 37:35Occupational wise, is a waitress.
• 37:37And family history, no significant
• 37:39family history.
• 37:41Continuing on, on review of
• 37:43systems, she reports over the
• 37:45last eight months feeling more
• 37:47tired, and her IBS symptoms
• 37:49of bloating and diarrhea are
• 37:51worse, which she attributes to
• 37:52work related stress.
• 37:54Labs wise, she shows a
• 37:56hemoglobin
• 37:57of nine from down from
• 37:58eleven.
• 37:59Iron studies show persistent iron
• 38:01deficiency.
• 38:03She has not been taking
• 38:04iron because she feels it
• 38:06makes her
• 38:07abdominal symptoms worse.
• 38:09A lab somewhat improved after
• 38:11IV iron,
• 38:12repletion,
• 38:13but her symptoms continued to
• 38:15get worse, and she was
• 38:16referred to GI.
• 38:17Colonoscopy
• 38:18was done, which showed a
• 38:20sigmoid mass, and biopsy showed
• 38:22adenocarcinoma.
• 38:27So at this point, what
• 38:29parts of our history is,
• 38:31standing out? What are some
• 38:33special considerations for young adults
• 38:35who are diagnosed with cancer?
• 38:36And with that, I'd like
• 38:37to, hand it over to
• 38:38Tejal, please.
• 38:40Yeah. Thank you so much.
• 38:41I think, this is, one
• 38:43of our greatest fears is
• 38:45that we're seeing
• 38:47younger and younger people being
• 38:49diagnosed
• 38:51with not only colorectal cancer,
• 38:52but other cancer types as
• 38:54well,
• 38:55every single day.
• 38:56And
• 38:57this is,
• 38:59you
• 39:00know, based on a patient
• 39:01who I've seen recently
• 39:03and a story that we're
• 39:04hearing over and over again.
• 39:06Someone who was otherwise healthy
• 39:08has no family history, really
• 39:11not much in terms of
• 39:12risk factors,
• 39:13and
• 39:14they
• 39:15had been doing well until
• 39:16they weren't. And
• 39:18they come to this complete
• 39:20shock of getting a diagnosis
• 39:21of cancer at such a
• 39:22young age.
• 39:24So, I think,
• 39:27that the fact that we're
• 39:28seeing these trends and what
• 39:29we'll be talking about more
• 39:31is
• 39:32when you are having
• 39:34these unexplained
• 39:35and these persistent symptoms,
• 39:38even in our younger and
• 39:39healthier patients, we need to
• 39:41be acting on them. We
• 39:42need to be picking them
• 39:43up and we need to
• 39:44get further evaluation
• 39:46promptly.
• 39:47So,
• 39:49as I mentioned,
• 39:51we've been seeing
• 39:53data over and over again,
• 39:55and you've probably read in
• 39:56the news
• 39:57that we're seeing rising rates
• 39:58and increasing incidence of what
• 40:00we term as early onset
• 40:01colorectal cancer.
• 40:03When I say the term
• 40:04early onset, I'm specifically
• 40:07referring
• 40:08to adults who are diagnosed
• 40:09under eight under the age
• 40:10of forty nine, although that's
• 40:12not a strict definition.
• 40:15And as this graph depicts,
• 40:17not only are we seeing
• 40:19an increasing incidence,
• 40:21but we're also seeing that
• 40:23while mortality
• 40:24had been decreasing
• 40:26for a very long time,
• 40:28we then saw the mortality
• 40:30in this young adult population
• 40:32plateau and now actually looks
• 40:33like it's starting to increase.
• 40:36I think one of our
• 40:37biggest questions is why is
• 40:39this happening?
• 40:40And we don't have a
• 40:42great explanation. The reality is
• 40:43that it's probably
• 40:45multiple different factors that are
• 40:47interacting.
• 40:49It might be, you know,
• 40:50the fact that we are
• 40:51having increasing rates of obesity
• 40:54and sedentary lifestyle. There's maybe
• 40:56something in the environment, what
• 40:57we're eating, what we're drinking,
• 40:59something that we're exposed to,
• 41:01all of these things that
• 41:02might be changing
• 41:04our gut microbiome
• 41:05and may lead to more
• 41:07of an inflammatory
• 41:08phenotype,
• 41:09which might be increasing our
• 41:10chances of cancer.
• 41:12But we don't have any
• 41:14sort of slam dunk explanation,
• 41:16And there's a lot of
• 41:17research that's going on and
• 41:19trying to figure this out.
• 41:21Now,
• 41:23what's
• 41:24I think challenging, not only
• 41:26about the fact that we're
• 41:27getting the diagnosis
• 41:29of cancer in these younger,
• 41:31people,
• 41:32but oftentimes
• 41:34we're catching them late.
• 41:36We're seeing
• 41:37young people present with advanced
• 41:39disease by the time that
• 41:41they're diagnosed.
• 41:43Some of it might
• 41:44be the fact that the
• 41:45biology of the cancer itself
• 41:47might be,
• 41:48some, a little bit more
• 41:49aggressive.
• 41:50But there are a lot
• 41:51of other factors as well.
• 41:53There are,
• 41:54factors related to the patients
• 41:55themselves. They might be ignoring
• 41:57symptoms they have. They might
• 41:58think, oh, I'm healthy otherwise.
• 42:00I'm just not feeling great
• 42:02right now.
• 42:03And so that might mean
• 42:04that they are not looking
• 42:06for care. A lot of
• 42:07young people don't have primary
• 42:09care doctors. And so by
• 42:10the time they something is
• 42:12wrong, it takes them a
• 42:12long time to actually get
• 42:14in to see someone.
• 42:15There's also a lot of
• 42:16fear around this diagnosis, some
• 42:18embarrassment as well.
• 42:20There's also factors that might
• 42:21be related to the physicians
• 42:23that lead to to to
• 42:24the delay. They might
• 42:26miss symptoms, or they might
• 42:27attribute
• 42:28some of the symptoms to
• 42:30other more common
• 42:32diagnoses.
• 42:33A lot of these presenting
• 42:34symptoms can be vague. It's
• 42:35it's not
• 42:36most of the time, it's
• 42:38not clear.
• 42:39And this might mean that
• 42:41there are delayed referrals and
• 42:42further examination.
• 42:44And then ultimately, there are
• 42:45a lot of system related
• 42:47days delays,
• 42:48limited resources in terms of
• 42:50providers, particularly
• 42:52in rural areas.
• 42:54The appointments are delayed. We're
• 42:56needing more and more help
• 42:58to take care of this
• 43:00population, but we just aren't
• 43:01able to meet it with
• 43:02the resources that we have
• 43:04available to us.
• 43:07Now when a young adult
• 43:09is diagnosed with colorectal cancer,
• 43:12there are some unique things
• 43:14to consider that may not
• 43:16be
• 43:17necessarily as much in the
• 43:18forefront in our older patients.
• 43:21For example,
• 43:23you know, this young woman,
• 43:24she might still be wanting
• 43:26to have more children. So
• 43:27fertility is a consideration.
• 43:29And how do the treatment
• 43:30options that we have for
• 43:31colorectal cancer
• 43:33relate to that and have
• 43:34impact
• 43:35that. Their unique family dynamics.
• 43:38This young adult population oftentimes
• 43:40will have young children, toddlers.
• 43:42They might also taking care
• 43:44of their elderly parents as
• 43:45well.
• 43:47Sometimes they are the primary
• 43:48care the primary,
• 43:50breadwinners in the family in
• 43:51terms of their career. They
• 43:52might be the only one
• 43:53in their family
• 43:54who is making money, and
• 43:56so they may not be
• 43:57able to be taking the
• 43:59time off to actually get
• 44:00their treatments.
• 44:02They also might feel more
• 44:03isolated because other people who
• 44:05are their same age aren't
• 44:06dealing with these serious diagnoses.
• 44:08So that's even more of
• 44:10a psychosocial stress on them.
• 44:13And they're more likely to
• 44:14have a genetic,
• 44:16reason for having their colorectal
• 44:18cancer diagnosed, which also has
• 44:20its own implications.
• 44:21And so I think for
• 44:22all of these reasons, there's
• 44:24a real,
• 44:25opportunity
• 44:26here for our oncologists to
• 44:28partner with, primary care who
• 44:31know these patients the best
• 44:32and have followed them for
• 44:35much longer than the oncologist
• 44:36has
• 44:37to work through the holistic
• 44:39picture.
• 44:40At Yale,
• 44:41we've started an early onset
• 44:43cancer program to do just
• 44:44this and to help to
• 44:45address all of these issues
• 44:47in addition to their cancer
• 44:49care specifically.
• 44:52And then just to,
• 44:54share a little bit, like,
• 44:55I love those, unique considerations
• 44:57that you spoke about, Dejal.
• 44:58It's,
• 44:59very challenging with such a
• 45:01young diagnosis. And that's really
• 45:02where our primary care clinicians
• 45:04can be that bridge with
• 45:06our oncology specialists and be
• 45:07there for that holistic care,
• 45:09holistic approach. So,
• 45:10again, really, really important.
• 45:13Going back to the case
• 45:14now,
• 45:15the patient was diagnosed with,
• 45:17stage three sigmoid colon cancer,
• 45:20and she successfully underwent treatment
• 45:22with surgery and,
• 45:24adjuvant,
• 45:25chemotherapy.
• 45:26She followed with oncology for
• 45:28five years without evidence of
• 45:29disease recurrence, but has ongoing
• 45:32challenges?
• 45:34So as I mentioned earlier,
• 45:36surveillance for colorectal cancer per
• 45:38our national guidelines
• 45:40is recommended to follow for
• 45:41five years.
• 45:42But it, the buck doesn't
• 45:44stop there. The impacts of
• 45:46having a cancer diagnosis, both
• 45:48physically, but also mentally, emotionally
• 45:52far
• 45:52outlast
• 45:53that five year time mark.
• 45:56There are multiple considerations
• 45:58that,
• 45:59that should be,
• 46:01thought about
• 46:02when the care of this,
• 46:04patient shifts
• 46:06more primarily or almost completely
• 46:08back to the primary care
• 46:10doctor at that five year
• 46:11time point.
• 46:12It's not only the physical
• 46:14consideration. So there might be,
• 46:17multiple things to consider in
• 46:19terms of the physical aspect
• 46:20of it. Maybe they have
• 46:21a permanent ostomy.
• 46:23Maybe they have permanent neuropathy
• 46:25from the chemotherapy they had,
• 46:27or they might be at
• 46:28higher risk for another cancer
• 46:29because of the chemo they
• 46:30had. They might look different.
• 46:32They might feel different. They
• 46:34might have
• 46:35fertility impact.
• 46:36There's countless things physically,
• 46:38but but it goes beyond
• 46:40that too. Psychologically,
• 46:42there's trauma from having the
• 46:44diagnosis in the first place.
• 46:46And we hear from our
• 46:47patients that sometimes
• 46:49when the five year mark
• 46:50is done, they sometimes feel
• 46:52forgotten about.
• 46:53But the truth is that
• 46:55experience that they have is
• 46:57gonna shape them for the
• 46:58rest of their lives.
• 46:59And, again, this may have
• 47:01longer term impacts in their
• 47:02social life in general as
• 47:03well. Maybe they need accommodations
• 47:05at work now. Maybe they
• 47:06had to interrupt their education.
• 47:08It's certainly impacted the relationships
• 47:10of their friends and family
• 47:11around them. So we have
• 47:13to be thinking about all
• 47:14of these things
• 47:15for long into the future
• 47:17when taking care of all
• 47:19of our patients,
• 47:20but in particular for our
• 47:22young adults who do have
• 47:23that lead time and that
• 47:25that long runway ahead of
• 47:26them beyond their cancer diagnosis.
• 47:31Hundred percent echo everything that
• 47:33you're saying. And then just
• 47:35a few just key,
• 47:36discussion points. You know, colorectal
• 47:38cancer incidence is increasing in
• 47:40young adults less than an
• 47:41age fifty years old even
• 47:43with though those without clear,
• 47:46risk factors or family history.
• 47:48And vigilance is needed,
• 47:50to diagnose early. So getting
• 47:52a thorough history
• 47:53and not not dismissing,
• 47:56symptoms, vague symptoms in young
• 47:58adults is very important for
• 48:00us from the primary care
• 48:01side.
• 48:02Oncology and primary care can
• 48:03partner to help provide holistic
• 48:05care to patients,
• 48:07and, again, especially that aftercare,
• 48:09right, so that patient doesn't
• 48:10feel forgotten
• 48:11and are being being followed
• 48:13through afterwards.
• 48:15And then with that, I
• 48:16think I was gonna share
• 48:18hand over to Tejal again.
• 48:19Yeah. So, doctor Yore has
• 48:22already,
• 48:23brought this up, but, you
• 48:24know, the question is what's
• 48:25next? What's happening now, And
• 48:27where are we looking for
• 48:28in the future?
• 48:29And I think that's where,
• 48:32these novel technologies such as
• 48:34the blood test blood piece
• 48:35testing that was already discussed
• 48:37has a lot of promise
• 48:38and a lot of excitement.
• 48:41You know, the idea that
• 48:42someone can just get a
• 48:43blood test the same time
• 48:44as they get all their
• 48:45other labs and have that
• 48:46be a part of their
• 48:47colon cancer screening as well
• 48:49as other cancer screenings eventually
• 48:51is really exciting and might
• 48:53help to overcome some of
• 48:54those barriers that we are
• 48:56facing
• 48:57from a systematic standpoint
• 48:59for our patients.
• 49:00But as was already addressed,
• 49:02you know, our current technology
• 49:04is limited. So I think
• 49:06there's a lot more that
• 49:07is undergoing in terms of
• 49:09research right now and and
• 49:10a lot more to look
• 49:11forward to in the future.
• 49:15Excellent.
• 49:16And then with that, we'd
• 49:17like to share a few
• 49:18final, key points to take
• 49:20away from this lecture.
• 49:22One being consider all types
• 49:24of screening options.
• 49:25If we think back to
• 49:26our first patient,
• 49:28they were appropriately screened with,
• 49:30Cologuard.
• 49:31They were due for another
• 49:32Cologuard because they were at
• 49:34around, the year three year
• 49:35mark. Right?
• 49:37However, it was a case
• 49:38of rectal bleeding. Right? So
• 49:39that's when we shifted from
• 49:41screening to more diagnostic,
• 49:43and that's where the colonoscopy
• 49:45was more appropriate. So being
• 49:46able to identify
• 49:48the different types of modalities
• 49:50and, when to use what
• 49:52is very important for us.
• 49:54Do not dismiss mild rectal
• 49:55bleeding, needs close follow-up.
• 49:58Early detection of colorectal cancer
• 50:00is key for treatment options
• 50:01and survival.
• 50:03Taking a very thorough family
• 50:04history is key wherever possible.
• 50:07Colorectal cancer incidence is increasing
• 50:09in young adults,
• 50:11even without clear, risk factors.
• 50:13So we have to be
• 50:14vigilant to try to make
• 50:15an early diagnosis.
• 50:17And then very importantly, partnering
• 50:18with our colleagues, our GI
• 50:20specialists, our oncology specialists,
• 50:23especially when there's ambiguity
• 50:25or we have any suspicion
• 50:26for red flags is, very
• 50:28important.
• 50:29Taking a team based approach
• 50:30is, key for our patient
• 50:32care.
• 50:33With that, I'd like to
• 50:34open up to our colleague,
• 50:35specialist colleagues. Is there any
• 50:37other final,
• 50:39thoughts or wisdom pearls that
• 50:40you would like to share?
• 50:46Thanks, Pia. I think you
• 50:47really hit the nail on
• 50:48the head there in terms
• 50:49of this is
• 50:50a collaboration
• 50:52between
• 50:53multiple different groups. And I
• 50:55think
• 50:56communication
• 50:57between
• 50:58the, you know, patients and
• 51:00their providers is so important.
• 51:01But the communication
• 51:02between
• 51:03the different providers from different
• 51:04specialty groups is just as
• 51:06important.
• 51:07And building that relationship, increasing,
• 51:10you know, the education, not
• 51:11only among our medical community,
• 51:13but going out there and
• 51:15seeing meeting our patients where
• 51:17they're at, understanding where their
• 51:19barriers are, hearing from them,
• 51:20meeting with community stakeholders.
• 51:23I think that is so
• 51:24important
• 51:25to understand,
• 51:28you know, what what truly
• 51:30are the the challenges that
• 51:32our patients are facing and
• 51:33hearing from their voices
• 51:35can really help us as
• 51:37well, not only with the
• 51:38barriers that we know about,
• 51:39but those that we may
• 51:41not know, and also to
• 51:42help the disparity in care
• 51:44that we see as well.
• 51:45You're you're preaching to the
• 51:47choir. I echo everything that
• 51:48you say.
• 51:51I just wanna remind
• 51:53attendees, you can enter questions,
• 51:56in the q and a
• 51:57as we continue
• 52:00to have a discussion amongst
• 52:01our panelists.
• 52:02Tracy, I didn't know, Doctor.
• 52:04Battaglia, I didn't know if
• 52:05you had any questions. You
• 52:06have a huge interest in
• 52:08disparity in cancer screening. What
• 52:09what are some of the
• 52:10questions that you had, for
• 52:12the panel? Yeah. I mean,
• 52:14I think that first of
• 52:15all, thank you for that
• 52:16wonderful discussion and dialogue. And,
• 52:18I think
• 52:19fear is my first emotion
• 52:21that I'm having in listening
• 52:23to this presentation
• 52:24for two reasons. Two of
• 52:26the cases that you presented,
• 52:28you
• 52:28know, common things are common
• 52:30in young people.
• 52:31Right? And so, you know,
• 52:34constipation
• 52:35and rectal bleeding
• 52:37one time. Like, what does
• 52:38close follow-up mean, and how
• 52:40much
• 52:41do we tolerate
• 52:42clinically
• 52:43before we sort of pull
• 52:44the trigger on a diagnostic
• 52:46test? And similarly, in a
• 52:47young menstruating female who has
• 52:49IBS,
• 52:50like, wow.
• 52:52Like, can you just speak
• 52:53a little bit more about
• 52:54that? Because I think this
• 52:55is our worst nightmare as
• 52:56a primary care physician is
• 52:58missing something like this. But
• 52:59yet every day in our
• 53:01practices, we're hearing these kinds
• 53:02of symptoms.
• 53:04I'll just say, you know,
• 53:06when we had iron deficiency
• 53:07anemia,
• 53:08you know, being a a
• 53:09premenopausal woman was like a
• 53:11get out of jail free
• 53:12call. Right? That meant you
• 53:13did not need to investigate
• 53:15colorectal. That's right. Source of
• 53:17blood loss, and it's just
• 53:19no longer true. Mhmm.
• 53:23I I think our threshold
• 53:24has gone down dramatically responding
• 53:26precisely to that, and we
• 53:28should. And and,
• 53:29and, yeah, we could be
• 53:32extremely sensitive and overload our
• 53:34system.
• 53:35But a close follow-up on
• 53:37on things that are not
• 53:38that clear, a very close
• 53:40follow-up
• 53:41and and whenever we don't
• 53:42feel comfortable just going ahead
• 53:44with the diagnostic test for
• 53:46sure. I think we all
• 53:47have responded to that, and
• 53:48probably we just have to
• 53:49be more sensitive because what
• 53:51was say was saying. I
• 53:52mean, the the
• 53:53see, everyone
• 53:55born after nineteen sixty has
• 53:56a much higher risk of
• 53:58not only colon but other
• 53:59cancers. So we can approach
• 54:01things
• 54:02business as usual. We have
• 54:03to be much more vigilant
• 54:05and more aggressive, to tell
• 54:06you truth, with with symptoms.
• 54:08Yeah. And then I was
• 54:10just thinking for that third
• 54:11case, would we want to
• 54:12get, like, a serial h
• 54:13and h? Like, how frequent
• 54:15would we check
• 54:16the the hemoglobin there?
• 54:20Yeah. I mean, I think
• 54:20it really depends on on
• 54:23the the context, but,
• 54:26exactly
• 54:26what we have been discussing,
• 54:28you know, if
• 54:29there's anything that is persisting
• 54:32or anything that's not just
• 54:34doesn't feel right, if they
• 54:36aren't responding the way that
• 54:37that you'd expect them to,
• 54:40I think there should be
• 54:41a very low threshold
• 54:43to just
• 54:44ask, to just get checked
• 54:46out. And, of course, that's
• 54:47much easier
• 54:49said than done for the
• 54:51reasons that we've already discussed
• 54:52as well in terms
• 54:53of systems limitations and provider
• 54:56limitations and,
• 54:57all the barriers there are
• 54:58to get care in the
• 54:59first place. But I think
• 55:01that's when, again, the communication
• 55:03between providers can be very,
• 55:05very
• 55:06helpful. You know, you make
• 55:07a great point there, Dejal.
• 55:09I'm just thinking back to
• 55:09another case I had, earlier
• 55:12last week where I didn't
• 55:13formally, consult oncology, but just
• 55:16having a relationship with one
• 55:17of our, heme oncologists in
• 55:19Greenwich Hospital, Doctor. Montanari, I
• 55:21was able to do, like,
• 55:22a soft consult and come
• 55:23up with a strategy.
• 55:25And then we ended up
• 55:26going a different route than
• 55:27going straight to, heme oncology
• 55:30to, make it more effective
• 55:32for the patient. So,
• 55:34just to summarize our relationships,
• 55:35collaborating with our colleagues,
• 55:38it's so important. It's an
• 55:39investment for patient care, right,
• 55:40to give better patient care.
• 55:44I wonder if I can
• 55:45follow-up on that,
• 55:47sort of this line of
• 55:49sort of discussion.
• 55:50It relates to sort of,
• 55:51like, how long is too
• 55:53long to, like, wait in
• 55:54terms of delay. Mhmm. And
• 55:56we know that access in
• 55:57our system
• 55:58across the country is far
• 56:00from perfect. And sometimes we
• 56:02have to advocate as primary
• 56:03care physicians to make sure
• 56:05that colonoscopy gets prioritized or
• 56:07that consultation,
• 56:09you know, with whatever specialty
• 56:10gets prioritized. And, unfortunately, we
• 56:13don't necessarily have
• 56:15safety net systems in our
• 56:16all of our practices to
• 56:17be be sort of managing
• 56:19all of that. And so,
• 56:20you know, is it, like,
• 56:21a three month mark? Like,
• 56:22that was just, like,
• 56:24just unacceptable?
• 56:25Or I mean, obviously, I
• 56:27understand your index of suspicion
• 56:29is gonna sort of dictate
• 56:30that. But, like, in that
• 56:32case, for that that young
• 56:33woman, she's a stage three.
• 56:35Is that right?
• 56:38Yes. So, like, was there
• 56:40a long delay in her
• 56:42diagnostic workup?
• 56:45I mean, that probably developed
• 56:47over the course of months.
• 56:49And, I would say, although
• 56:50she might have had a
• 56:51precancerous
• 56:52lesion
• 56:54over a year or more
• 56:55Right. Than that.
• 56:57So,
• 56:59I think,
• 57:01it's it's it's truly challenging.
• 57:02And I think
• 57:03this is where
• 57:05I'm really excited
• 57:06about
• 57:07the
• 57:08developing technology
• 57:10to see
• 57:11what can we
• 57:13take, you know, have as
• 57:15a pressure release valve from
• 57:16our system.
• 57:17Can we transition
• 57:19some of these really time
• 57:20and resource,
• 57:22intensive,
• 57:24screening methodologies
• 57:25to things that are more
• 57:26accessible?
• 57:27And can that improve equity
• 57:29in the care there, not
• 57:30only in terms of access,
• 57:31but actually delivery as well.
• 57:33But we're not there yet.
• 57:35Doctor Iohr, do you have
• 57:36thoughts? Well, I'm I'm it
• 57:37just comes up to my
• 57:38mind right away at the
• 57:39screening level,
• 57:41how we our data nationwide
• 57:43in terms of follow-up colonoscopy
• 57:46after a positive stool
• 57:48based test, which is about
• 57:49sixty percent over a year.
• 57:51So
• 57:52that's not good.
• 57:54That has a lot to
• 57:55do because for a lot
• 57:56of reasons, one of them
• 57:57is that we have not
• 57:58fully developed a system that
• 58:00prioritizes
• 58:01things appropriately.
• 58:02And if we do have
• 58:03a positive stool test, that's
• 58:05not,
• 58:06no longer an elective thing.
• 58:07That's something that needs to
• 58:08happen,
• 58:09within six months, and there
• 58:11and the six months is
• 58:12no,
• 58:13no soft number is that
• 58:14we know that really after
• 58:16six and and more after
• 58:18nine months,
• 58:19prognosis does change. Therefore,
• 58:22this is something you have
• 58:23to to deal with, and
• 58:25I think it does call
• 58:27for that system wide reorganization
• 58:30and and calling more on
• 58:32on really risk stratifying.
• 58:34If we have a low
• 58:35risk person,
• 58:37maybe those were the people
• 58:38who are who can benefit
• 58:39the most from the non,
• 58:41nonaggressive
• 58:42screening options and then make
• 58:44sure that we have the
• 58:45availability
• 58:46for all these positive stool
• 58:48tests and for everyone who's
• 58:49at higher than average risk.
• 58:51So I think it does
• 58:53take us to think,
• 58:55in a more global way.
• 58:57As we were talking about
• 58:58this, Tejal was talking to
• 58:59us about the early onset
• 59:00cases, we can't just work
• 59:02on silos here because the
• 59:04the needs of our patients
• 59:05are much more complex than
• 59:06that. And so we need
• 59:08to understand
• 59:09our,
• 59:10our,
• 59:11capacity and our availability
• 59:13to really make sense of
• 59:14it to care for patients
• 59:16in the most proper way,
• 59:17and not everyone getting the
• 59:19same thing because not everyone
• 59:21is gonna benefit the same
• 59:22way if we give them
• 59:23the same things.
• 59:24Yeah. There's two key things,
• 59:26you know, Shavira, from having
• 59:27participated in other talks with
• 59:29you. I mean, it's it's
• 59:29really clear
• 59:31that having a system
• 59:32for cancer screening. Right? It
• 59:34it's not just whether they're
• 59:35behind closed doors with any
• 59:36one
• 59:37clinician. The whole organization works
• 59:39on a system
• 59:40for making sure that people
• 59:42get screened and then adding
• 59:43in risk stratification,
• 59:46you know, for most proper
• 59:47use of resources, I think,
• 59:49is is is really good.
• 59:50And we have drawn to
• 59:52the end of our hour.
• 59:54And, you know, we almost
• 59:55went over because this was
• 59:57pretty interesting and incredibly well
• 59:59presented. So thank you so
• 01:00:00much,
• 01:00:01to each of our panelists,
• 01:00:03for all of your words
• 01:00:05of wisdom
• 01:00:07to us tonight.
• 01:00:09And, thank you, Tracy, for
• 01:00:11co hosting with me, and
• 01:00:12thank you everybody who attended
• 01:00:14or who is watching this
• 01:00:15later.
• 01:00:16Thank you. Thank you so
• 01:00:17much.
• 01:00:18Bye. Take care.