Advances in Colon and Rectal Surgery

December 06, 2021

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December 5, 2021

Yale Cancer Center

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00:00Funding for Yale Cancer Answers
00:03is provided by Smilow Cancer
00:06Hospital and AstraZeneca.
00:08Welcome to Yale Cancer
00:09Answers with your host
00:10Doctor Anees Chagpar.
00:13Yale Cancer Answers features the latest
00:14information on cancer care by
00:16welcoming oncologists and specialists
00:18who are on the forefront of the
00:20battle to fight cancer.
00:22This week, it's a conversation about colorectal cancer
00:24with Doctor Ira Leeds.
00:26Dr. Leeds is an assistant professor of
00:28surgery at the Yale School of Medicine,
00:30where Doctor Chapgar is a
00:32professor of surgical oncology.
00:34Ira, maybe we can start
00:36off by laying the groundwork.
00:38Tell us a little bit
00:40about colorectal cancer.
00:41How common is it?
00:42How lethal is it?
00:44How many people get it?
00:46I'd be happy to.
00:47Colorectal cancer is one of the most
00:49common cancers worldwide.
00:51It's the third most common cancer and
00:58concerningly,
00:59it's also the second most lethal cancer
01:01by number of total cancer deaths.
01:03The good news
01:04on the colon cancer side of
01:06things is that early detection
01:08has survival rates of over 90% whereas
01:12late detection has rates of 15%,
01:15so it really gives us
01:17an important urgency in the
01:19cancer care community to identify
01:21individuals with
01:23precancerous lesions early because the
01:25survival difference is significant.
01:27To put it in kind of very real terms,
01:341 in 20 individuals in their lifetimes
01:36will have colorectal cancer,
01:38and so it's something where all of
01:40us probably know someone or will
01:42know someone or been affected.
01:52And speaking of early detection,
01:56tell us a little bit more
01:57about the screening guidelines.
01:59I understand that those have
02:01changed recently so that younger
02:04people now are being recommended
02:06to get colorectal screening.
02:08Is that right?
02:10That's absolutely correct.
02:11The screening guidelines continue
02:13to evolve and have for many years.
02:15The age of 50 was the magical
02:18number where everyone should be
02:20lining up to get colonoscopies or
02:22alternatives to colonoscopies for
02:24their colorectal cancer screening.
02:26Many, if not almost all
02:29societies that provide guidelines
02:31on this topic have moved to 45 as
02:35the new age when people should start
02:37screening for colorectal cancer,
02:38that's for average risk individuals.
02:40So there's a number of individuals,
02:41both with more rare diseases that
02:44predispose themselves to colorectal cancer,
02:46but also a particularly high risk
02:48sociodemographic groups, for example,
02:50African Americans who have earlier
02:53screening guidelines as well.
02:55Interestingly,
02:55one of the other
02:56parts of the guidelines that's
02:59always a discussion point
03:00when guidelines come up is
03:02how do you screen?
03:03Colonoscopy has been the
03:05gold standard for decades.
03:07Colonoscopies require you to typically
03:08get a little bit of sedation,
03:11and it's a procedure where you have
03:12to take a bowel prep the night before,
03:14so it's certainly a bit of a burden
03:17on the average person to do so.
03:19There are alternatives to colonoscopies.
03:21There are a number of reasons
03:23why a colonoscopy is arguably
03:25better for people that
03:26are able to adhere to the schedule,
03:28but the guidelines do really try
03:29to balance the burden of screening
03:31along with the benefits of screening.
03:34Let's talk a little bit
03:36about a few things that you
03:38touched on.
03:40So the first point is that screening is now
03:43being recommended at 45 rather than 50.
03:46Is that because the demographics
03:48of colon cancer are trending
03:51towards younger populations?
03:57And who gets colon cancer in terms
03:59of the age demographic?
04:02So the trends in colorectal cancer are,
04:06at the very least, interesting, and
04:09potentially concerning in many ways.
04:11New onset of colon
04:14cancer is actually declining nationwide.
04:18The overall rate of colorectal cancer
04:20in the United States is declining and
04:22and also favorably the mortality rate
04:24from colorectal cancer is declining,
04:27and we attribute those overall
04:29trends to fairly good adherence to
04:32colonoscopy and colonoscopy
04:35alternative screening schedules
04:37in older individuals that are
04:38getting good colonoscopies and
04:40the adherence to that currently is
04:41about 60 to 70% of people that are
04:43supposed to be getting them on time.
04:45The risk of colorectal cancer
04:48occurring in those patients seems
04:50to be declining and we attribute
04:52that to better screening.
04:54The concerning part is that in young people,
04:56which is defined as
04:5820 to 49 years old,
05:00the rate of colorectal cancer is
05:03increasing and that is concerning
05:04not just because that's a patient
05:06population that historically has not
05:08been screened and one of the major reasons
05:11why the guidelines were changed to 45.
05:13But we also don't know why the rate of
05:16colorectal cancer incidence is occurring
05:18more frequently in that younger population.
05:21So for those of us that
05:23think about this every day,
05:24it's relatively easy to agree that
05:26the screening guidelines
05:28should be lowered to younger ages
05:30and 45 is where it is now and
05:33in a completely unofficial
05:36role I would not be surprised if
05:39those guidelines potentially got
05:40even earlier in future years,
05:42but we don't know at all why there
05:44is a higher rate of
05:47cancer in that population.
05:50The other thing that you mentioned was
05:53that these guidelines are for average
05:54risk people and that there are a number
05:57of things that increase a person's
05:59risk of developing colorectal cancer.
06:00So you mentioned certain demographic
06:02groups such as African Americans.
06:05I was wondering if you could talk a little
06:08bit more about some of the conditions,
06:10genetic conditions,
06:12other predisposing factors that
06:15increase a persons risk and whether
06:18those people should be screened
06:21earlier than the 45 year old guideline?
06:25When we think about a risk factor,
06:26as I always try to break them down
06:28into what I call non modifiable
06:30versus modifiable risk factors.
06:31So non modifiable risk factors or
06:34the risk factors that an individual
06:36has an increased risk based on
06:38compared to the average population.
06:39But at the same time there isn't a lot
06:41that could be done about that other
06:43than changing a screening schedule
06:45to suit that increased risk which is
06:47modifiable or things that we really
06:48spend a lot of time talking to patients
06:51about because those are risk factors
06:53that if certain behaviors are changed,
06:55may actually reduce their risk.
06:58Increasing age is probably the
07:00one that's most frequently cited
07:01as a nominal risk factor.
07:03We cannot get younger overtime and we
07:05need to recognize that as we get older,
07:07we do have an increased
07:09risk of colorectal cancer,
07:10which is why screening continues after
07:12that first episode of colonoscopy at
07:15the original age of 50 and now 45.
07:18Family history and personal history
07:20are both incredibly important.
07:23Almost all the screening guidelines have
07:25a carve out for patients who have
07:28early onset colon cancer in a family
07:30member and most of the guidelines
07:31say that an individual should start
07:34their own personal screening 10 years
07:37before the age of onset
07:39in a first degree relative.
07:42The thinking there being that
07:44there is this idea that is widely
07:47accepted that most colorectal cancer
07:50comes from polyps that form in the colon,
07:53which is from the natural turnover
07:55of the surface of the colon,
07:59and so those polyps,
08:00then overtime have more and
08:02more turnover of cells,
08:03and those cells get increasingly
08:06cancer like and as that occurs
08:08in anywhere between a five
08:10and 10 year progression cycle,
08:11you can have what was a non cancerous
08:14polyp turn into a cancer.
08:15So that's where this thought that if
08:17you start 10 years before a primary
08:19relative who had colon cancer,
08:21you should be able to identify that
08:23at the precancerous stage and address
08:26it by removal with colonoscopy.
08:28There is also a personal history if
08:30certain patients have been exposed
08:32to various environmental factors or
08:38cancer causing agents,
08:41that would be another reason to
08:42screen them earlier and then there
08:45are relatively rare diseases,
08:46particularly inherited syndromes
08:48like Lynch syndrome or
08:50Familial adenomatous polyposis.
08:52These are conditions where
08:56numerous family members
08:59who have already had colon
09:01cancer or related cancers,
09:03and because of that increased risk,
09:05there are very well early
09:07screening guidelines for those
09:09particular patient groups.
09:11Those diseases and inherited
09:13symptoms are relatively rare,
09:15and typically patients are getting
09:16passed on from family members saying,
09:20I started screening earlier than average
09:21because of this and you should too.
09:30Tell us about the modifiable risk factors.
09:33So modifiable risk factors are incredibly
09:35important because this is where our
09:37patients own agency has something they can
09:39do to reduce their risk moving forward.
09:42There are things that we oftentimes
09:43don't like to hear about when
09:45we are patients ourselves,
09:46because it does typically
09:48involve behavior change.
09:49But you know, I really tried to have
09:51patients wrap their heads around that.
09:54You can essentially
09:55eliminate your increased risk if you
09:58do these changes in behavior early
10:01enough on in the exposure cycle and
10:03the modifiable risk factors that
10:05we think about most are alcohol use,
10:08tobacco smoking,
10:09being overweight or obese.
10:12And then the more controversial area
10:16are the dietary changes that one
10:19can do in addition to simple weight
10:21loss that's related to obesity.
10:23So, for example,
10:24this evidence is still evolving.
10:25We don't know for sure,
10:26but things like high fiber diets,
10:29reducing complex artificial sugars,
10:31and so forth may have an improvement
10:34on one's risk factors for colon cancer.
10:39The other one that
10:41I would controversially put in
10:42the modifiable risk factor
10:43group is race.
10:46Obviously a patient can't change their race,
10:48but I think at the society level
10:49we have to ask if whether or not
10:51the fact that African Americans
10:53in particular have an incredibly
10:55higher rate of colorectal cancer
10:57than the average population,
10:58is that because of something
10:59genetic and the data suggests that
11:01that's probably not the case.
11:02The data suggests that the risk of
11:05increased colon cancer in certain
11:07races is likely due to socioeconomic
11:09factors and access issues to care,
11:12so I think as a society and
11:14also as a group of physicians,
11:17Health care providers,
11:17we need to think seriously how we're
11:20making sure that race is acknowledged
11:22in our care of patients because
11:23there are increased risks that we
11:26likely could modify with improved
11:27access to care and addressing both
11:29social terms of health as well
11:31as biomedical risk factors.
11:34A couple of pointed questions.
11:36I guess the first is in terms of gender.
11:39Is there a difference
11:41in colorectal incidence?
11:44The relationship to gender and
11:46colorectal cancer has more to do with
11:48where the cancers occur in the colon,
11:51and this is a complex issue that we can
11:53probably come back to if we have time.
11:54But colorectal cancer occurs
11:56in three general places.
11:59The right side of the colon,
12:00the left side of the colon,
12:01and the rectum.
12:03These are very different areas
12:05in terms of how they are handled
12:07from a suregons standpoint,
12:08which is why it's really relevant and
12:11to go to your direct question,
12:14the gender differences between the
12:16various anatomic sites varies as well.
12:19We don't really understand why and
12:21it's an area of open investigation,
12:23but it does seem to color
12:25where these cancers occur,
12:27and therefore genders seem to have
12:29differences in treatment strategies
12:31because of where the sites of disease.
12:35So women have more colon cancers
12:37on one side of the colon than men?
12:40Correct, the right side.
12:42Interesting, and my second question,
12:44what about inflammatory bowel disease?
12:47Does that increase your
12:49risk of colorectal cancer?
12:50And if so, are we seeing more
12:54inflammatory bowel disease in
12:56younger people which might give
12:58us a clue as to one potential
13:01etiologic factor for younger onset?
13:05So, inflammatory bowel disease
13:07absolutely increases your risk.
13:10The screening guidelines for both
13:12patients with Crohn's disease and
13:15colitis specifically target those
13:18groups for early onset colonoscopies,
13:21partially to evaluate their
13:23inflammatory bowel disease,
13:24but also to evaluate for the early
13:27development of colorectal cancer.
13:30We talk a lot in that
13:32population about dysplasia.
13:33Dysplasia is what cells
13:34look like under a microscope when they're
13:37headed towards potentially being a cancer,
13:39and so those patients get routine regular
13:43biopsies to evaluate for dysplasia as
13:45a sign that that would be the case,
13:48and in that patient population the
13:50recommendations in terms of what
13:52you do with that are changing,
13:53but the historical recommendations
13:55have been to move towards early
13:57surgical intervention to remove
13:59diseased portions of the colon because
14:02of their increased cancer risk.
14:04You bring up an interesting point
14:06about inflammatory bowel disease
14:08incidence and early onset of colon cancers,
14:11and I think I would capture that
14:13more broadly,
14:14what one of the leading theories
14:16around why we have increased colorectal
14:19cancer in younger populations is
14:21the inflammatory burden that the
14:23colon is seeing younger in life.
14:25And there's a lot of reasons
14:26why that may be the case.
14:27The question has been raised,
14:29is it a matter of psychosocial
14:31stress and modern society?
14:33Is it a matter of
14:34the artificial sugar
14:37ingredients that are in food.
14:38Do they have
14:41an established higher
14:43inflammatory load that's seen by the
14:45body and is that somehow creating
14:47more inflammation in the colon?
14:49More inflammation begets this
14:50dysplasia that we talked about
14:52and does that lead to cancer?
14:53These theories are out there,
14:56they're often discussed and they
14:58have good biology that supports them.
15:01We just haven't made the missing
15:03link connection to the clinical evidence.
15:08Well, we're going to pick up the
15:10conversation right after we take a
15:12short break for a medical minute.
15:13Please stay tuned to learn more
15:15about the surgical care of colorectal
15:17cancer with my guest doctor
15:19Ira Leeds.
15:21Funding for Yale Cancer Answers comes
15:23from Smilow Cancer Hospital,
15:24where integrative medicine services
15:26help patients navigate physical,
15:28mental, and spiritual Wellness
15:30during and after cancer therapy.
15:32To learn more, visit
15:36yalecancercenter.org/integrative.
15:38The American Cancer Society
15:40estimates that more than 65,000
15:42Americans will be diagnosed with
15:44head and neck cancer this year,
15:46making up about 4% of all cancers
15:50diagnosed when detected early.
15:51However, head and neck cancers are
15:54easily treated and highly curable.
15:56Clinical trials are currently
15:58underway at federally designated
16:00Comprehensive cancer centers such
16:02as Yale Cancer Center and at Smilow
16:04Cancer Hospital to test innovative new
16:06treatments for head and neck cancers.
16:08Yale Cancer Center was recently awarded
16:11grants from the National Institutes
16:13of Health to fund the Yale Head
16:16and neck Cancer Specialized program
16:18of Research Excellence or SPORE to
16:21address critical barriers to treatment
16:23of head and neck squamous cell
16:26carcinoma due to resistance to immune
16:28DNA damaging and targeted therapy.
16:30More information is available at
16:33yalecancercenter.org you're listening
16:35to Connecticut Public Radio.
16:38Welcome back to Yale Cancer answers.
16:40This is doctor Anis Jaguar and I'm
16:42joined tonight by my guest Doctor Ira
16:44leads we're learning about the surgical
16:47care of patients with colorectal cancer.
16:49And before the break IRA we spent
16:52a lot of time talking about kind
16:55of what causes colon cancer,
16:57or at least what are some of the
17:00risk factors and what are the
17:02factors that lead to colon cancer,
17:04particularly occurring at
17:05a younger age so that.
17:08Guidelines have now changed
17:10to get colonoscopies earlier.
17:13One thing I want to talk about just
17:15before we get into the management
17:17of colorectal cancer is the type
17:19of screening you mentioned.
17:21This briefly before the break in terms
17:24of colonoscopy versus alternatives.
17:27It can you flesh that out a little
17:30bit for us so clearly nobody is,
17:32you know, chomping at the bit saying oh,
17:34sign me up I'd love to get a prep and
17:37have a tube put up my rear bottom end
17:40so that you can look at my colon,
17:42but we know that colonoscopy is a
17:45great test to find colorectal cancer
17:48early and allows one to actually
17:51remove potentially precancerous polyps.
17:54But if you're not terribly enthused
17:57about having a colonoscopy,
17:59how good are the alternatives and
18:01D recommend them?
18:03That's a loaded question
18:04when it's all said and done,
18:06but we'll try to break it up
18:08here into bite sized pieces.
18:10So I think to go to colonoscopy first, the.
18:13The two biggest values to colonoscopy
18:16for me are the following.
18:19The first is that colonoscopy has
18:21been shown to be able identify
18:23lesions typically earlier than a
18:25lot of the alternatives out there,
18:28and the reason being is that
18:30colonoscopy can dentify both truly
18:32benign what so non cancerous lesions
18:34it can identify precancerous lesions,
18:37and it can identify cancer and
18:39why that's valuable is that.
18:41It by getting your regular screening,
18:44colonoscopy.
18:44It kind of gives a time lapse image
18:47of what's happening in your colon,
18:49which I think is valuable.
18:51If something were to ever develop,
18:52kind of what somebody saw before.
18:55The second reason why colonoscopy is
18:56so valuable is that you're in there.
18:58You can already do what you need to do,
19:01oftentimes for these precancerous lesions,
19:04with almost every other screening test,
19:06it's going to basically stratify
19:08a patient to a low risk,
19:10meaning there was nothing detected
19:11on the tests or high risk group,
19:13which means that the test was abnormal,
19:15and therefore the patient needs
19:17a colonoscopy.
19:18So a lot of these,
19:19even the best non colonoscopy
19:23screening modalities are still routing.
19:25Folks,
19:25two colonoscopy when they have
19:27an abnormal test.
19:29So there is a little bit of this
19:30question of you know if there's
19:31so much that can be gleaned from
19:33a colonoscopy to begin with,
19:34should we putting everyone through
19:36the colonoscopy round and then,
19:37as I mentioned before,
19:38the the biggest argument against that,
19:40is that colonoscopy for some
19:41folks is has an undue burden,
19:44both in terms of pleasantness but also
19:46in terms of work loss and so forth.
19:48So if you can do,
19:49for example a stool test that
19:51you can do in your home at 1
19:54evening when you've got the time.
19:55To do it and send it off for analysis,
19:57and that if it's negative then you're done.
19:59You have no further burden on
20:00your day to day life to get your
20:02results you need to go back to
20:04being an average risk individual
20:06with no further colonoscopy needs.
20:08So I think we're the both the the.
20:13The clearance for these tests.
20:15In other words,
20:15what they're allowed to proclaim to be,
20:17and also where they really do,
20:18have a sweet spot as the average
20:21risk individual who's never had
20:22any abnormal findings on a prior
20:24colonoscopy and does not have
20:26the high risk family features
20:27that we talked about before those
20:30individuals if interested in
20:32pursuing a non invasive test like
20:35a colonoscopy have been shown to
20:38have equal benefit from one of the
20:40more advanced tests out there.
20:42It's basically a test that you
20:44give a stool sample and it uses a
20:47variety of assays or laboratory
20:49tests on that sample to look for both
20:51cancerous DNA in the stool as well as
20:54a signature of what a bleeding
20:56lesion in your colon might be like,
20:58which is one of the micro bleed
21:00is one of the hallmarks for pre
21:02cancer or early cancer in the colon,
21:05so that's what it's detecting and it's been
21:07shown to have a very good detection rate.
21:10And so if that's normal,
21:12then we can confidently say that
21:14patient does not need a colonoscopy if
21:16they have no other high risk features,
21:18there are a number of different options
21:19that are listed in the guidelines,
21:21but those two are probably the
21:23most common recommended today.
21:24The biggest drawback to the stool test that
21:27I mentioned is that it is quite expensive.
21:30Depending on insurance
21:31reimbursements and so forth,
21:33so it's not the biggest.
21:36The biggest benefit to it is
21:37the is the burden of going to
21:39get a colonoscopy more so than.
21:41Anything else in regards to
21:42resource use for it?
21:45Cool, so let's suppose you
21:47went for your colonoscopy,
21:49and a lesion was found.
21:52A polyp was found and biopsied and
21:54it turns out that it is a cancer.
21:57Can you help us to understand a
21:59little bit more about how you know
22:01whether this is kind of a good
22:03cancer where your colonoscopy
22:04has has gotten it and you don't
22:07need anything further versus a
22:08not so good cancer where there
22:10might actually be a need for you
22:13to see a colorectal surgeon and?
22:15Have more therapy done
22:17so there's a couple key things that
22:18you need to know when you as a
22:21surgeon when you're getting given a
22:23biopsy report from a colonoscopy.
22:24The things that we think about
22:26the most are for a true cancer is
22:30something called TNM staging or
22:32tumor nodes and metastasis staging.
22:34The tea or the tumor is what
22:36is happening at the microscopic
22:38level in terms of local invasion.
22:40Where is the thing that was biopsied?
22:42Where is it going?
22:43Is it in just the very first flute fuels
22:46level layers of cells of the colon?
22:49Is it invading through the colon?
22:50Is invading into other structures in
22:53as nodes or there are nodes lymph
22:55nodes that are basically the first
22:57sign that a colon cancer has been
23:00getting to spread beyond the original
23:02tumor and then finally, is Amar metastases?
23:05That means they're spread of the
23:07cancer beyond the colon,
23:08intestine into other organs.
23:10The body,
23:10most commonly the liver or the lungs.
23:13So four colon cancer that's been diagnosis.
23:15Colon cancer.
23:16On colonoscopy it is important to
23:18get a complete scan of the body of
23:21particularly of the chest and the
23:23abdomen to make sure that you don't
23:26have any far ranging metastases
23:28or or tumor spread.
23:30The second issue that is
23:32where does it look locally?
23:34And that's where sometimes
23:35the biopsy alone can do that.
23:37If the biopsy comes back as cancer
23:40and the entire polyp was not
23:42removed with that biopsy,
23:43then that's kind of the first step
23:45that someone needs to go back and see
23:47if that can be removed into Scopic Lee.
23:49Sometimes it's very obvious from the
23:51original colonoscopic exam that it's
23:53not going to be removed locally,
23:55but if it's on a stock,
23:56if it's kind of dangling into the colon,
23:58sometimes those are at a very
24:00good candidates for local removal
24:02with Columbus scope.
24:03If that's done and on the micro,
24:05the microscopic evaluation of that specimen,
24:08you can say clearly that here's
24:10the cut edge of where we took this
24:12tumor off this polyp off and there
24:14is no cancer at that.
24:16And then we looked at the individual
24:18cancer cells in the bulk of the
24:20polyp and we can see that they have
24:22certain features that are favorable
24:24then that may be all that patient needs.
24:27On the flip side,
24:28if there is tumor invasion,
24:29if there's high concerning features
24:31of the polyp in terms of what it
24:33looks like under the microscope,
24:34then that's something we're a segment of.
24:36The colon needs to be removed,
24:38and that would require a typically,
24:41and in 2021 it would typically
24:43require mentally invasive surgery
24:44to remove a segment of the colon and
24:46the nodal bundle that's attached to it.
24:48To get that end staging for very
24:51early tumors,
24:52the risk of an end spread meaning
24:54a nodal spread is so low that for
24:56those very early tumors that we
24:58just took off. Instead, we're done.
24:59Those don't need that nodal bundle,
25:01which is where that justification comes from.
25:03So Speaking of burden,
25:05if you had a very small cancer
25:08such that it was just in a polyp,
25:11do those patients still need the
25:13scans of their chest in their abdomen
25:15to look for distant metastases?
25:17One would think that if
25:18the nodal burden is low,
25:20then the distant metastases
25:21burden should also be very low.
25:24I think it's certainly consideration
25:25this is one of those particularly
25:27controversial points and staging
25:29guidelines that has is up for discussion,
25:32and I think shared decision
25:33making does come into it.
25:34This is something that either that a
25:36colorectal surgeon should probably involve
25:38with to talk to the patient about one on one,
25:40because there are very small risks up
25:44spread and that needs to be discussed.
25:48With the patient eventually,
25:49because those guidelines are in flux,
25:51and then if I can go back for one second,
25:53I think you know we we talked a lot about
25:55the kind of you see a polyp in the colon,
25:57just to kind of clarify,
25:58one of the tricky parts about the
26:00anatomic specificity that we mentioned
26:02earlier was that colon cancer can
26:04be dealt with and more with less
26:06the way that we just discussed.
26:07Whereas rectal cancer is a different bird,
26:09rectal cancer does make up about
26:1130% of all colorectal cancer,
26:13and the decision making around how
26:16to address those tumors does differ.
26:19OK, tell us more about that.
26:20How does it differ?
26:22So the interesting thing with
26:23rectal cancer is biologically,
26:24it's very similar to colon cancer.
26:26It looks very the same under the
26:27microscope and it's the same
26:29kind of cell story that created
26:30those cancers in the first place,
26:31where rectal cancer does differ
26:33is that it's anatomically fixed,
26:35meaning the ****** is fixed in the pelvis,
26:37whereas the colon flops around.
26:39It's an incredibly powerful difference
26:42that becomes more so every day
26:44because we realize that we have more
26:47modalities or options for therapy
26:48that we can use for rectal cancer
26:50because of its anatomically fixed.
26:52Position what this means in 2021 is
26:55that many many rectal cancers need
26:58chemotherapy and radiation upfront,
27:00which is entirely different.
27:01Colon cancer, which if anything,
27:03only gets those options for therapy
27:05after the original tumor is removed.
27:08Rectal cancer has been shown that it
27:10seems to do better if we give those
27:12modalities up front and then follow
27:14with surgery after considerable
27:15lead in period of often times,
27:17three to six months of chemo
27:19radiation therapy.
27:21This brings up an interesting point.
27:23Oftentimes, here on the show we we
27:26talk about multidisciplinary care and
27:28we talk about personalized therapy.
27:31So how do you decide which
27:33patients need chemotherapy?
27:35Which patients need radiation?
27:36Which patients do well with surgery alone?
27:40It the multidisciplinary point
27:42that you mentioned is critical.
27:44It's getting increasingly complicated,
27:46particularly with advanced disease.
27:48It's very hard to make these decisions
27:50without a colorectal surgeon,
27:52medical oncologists and a number
27:54of others supporting positions
27:56from radiology pathology.
27:58Interventional radiology all
27:59getting together to talk about
28:02what's the best course of action?
28:04There are a couple sort of
28:06easier points to make here.
28:07I think that for colon cancer that's
28:10early stage in the colon and not the
28:13****** that's typically a surgery
28:15first approach in most cases for things
28:18that are in that for rectal cancer
28:20as well as advanced colon cancer,
28:23it really does require everyone in the room
28:25to have that conversation about a patient.
28:28Ultimately,
28:28with the patient to see what's
28:31the best first line approach.
28:33Doctor Ira leads is an assistant professor
28:35of surgery at the Yale School of Medicine.
28:38If you have questions,
28:39the address is cancer.
28:40Answers at yale.edu and past editions of
28:43the program are available in audio and
28:46written form at yalecancercenter.org.
28:48We hope you'll join us next week to
28:50learn more about the fight against
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