Colorectal Cancer: New Treatment Advances and Innovations

March 10, 2022

Information

Smilow Shares | March 9, 2022 | Presentations by: Drs. Jeremy Kortmansky, Amit Khanna, Justin Persico, Hamita Sachar, Anne Mongiu, MD, and Kevin Du.

Co-Sponsored by: Colon Cancer Foundation

ID7524

To CiteDCA Citation Guide

00:00My name is Jeremy court Manske.
00:03I am a medical oncologist here at
00:06Smilow with a a focus in GI Oncology,
00:11I wanted to thank everybody for
00:13joining us on what I hope is the last
00:15gasps of winter before spring comes.
00:17But March is and is an important month,
00:21especially for those of us who
00:24care for patients with GI cancers,
00:26as it is colorectal cancer awareness Month.
00:29And so we have a, uh,
00:32a really important educational
00:34program today cosponsored with
00:37the Colon Cancer Foundation.
00:42And so I wanted to before we get
00:44even started, introduce Cindy
00:46Barassi to to get a skeleton.
00:51Thank you doctor. Court manske.
00:53I really appreciate it and I just want
00:55to welcome everyone and say First off,
00:57thank you to the Smile Center for having
00:59us and I want to say Happy March.
01:02Happy Colorectal Cancer Awareness month.
01:04So really special month for us here
01:06at the Colon Cancer Foundation.
01:08We are dedicated to a world without
01:10colon cancer, colorectal cancer.
01:12Again, my name is Cindy Barassi.
01:14I'm the President of the
01:16Colon Cancer Foundation.
01:17I also serve as a steering
01:19committee member on C5.
01:21Which is the New York City wide
01:24colon Cancer control coalition?
01:26I serve on the New York State Cancer
01:29Consortium as a cancer action team
01:32member and I serve on the family health,
01:36history and early age.
01:37Set colorectal cancer task force at
01:40the national colorectal cancer level.
01:42So quite involved in in colon
01:45cancer as all of you are,
01:48I'm going to share a few slides not
01:50take up too much of your time tonight.
01:52Just bear with me as I put those on.
01:59There we go OK.
02:01So we just went through all of that.
02:04So the Colon Cancer Foundation for stuff.
02:06Can you guys see that?
02:08Just if you could not for
02:09me that would be great.
02:10Perfect, we've been around for 19 years.
02:13We were founded by surgical oncologist.
02:15His name with Doctor Thomas K Webber.
02:17He we unfortunately lost him,
02:20ironically to another form of
02:21cancer a couple of years ago.
02:23But he, as all of you are was quite
02:26passionate about the disease and seeing
02:28too many patients walk into his office
02:31with a late stage of colon cancer.
02:33So he actually.
02:34Founded one of the nation's first
02:37walks and runs to raise awareness of
02:39the disease in the New York metro area
02:42called the Colon Cancer Challenge.
02:44And we're actually having the
02:4519th version of that walking run
02:47at the end of this month,
02:49month March 27th in Queens Flushing Meadows.
02:52So we would love for all of you
02:54to join us at that event so we
02:57have 3 prongs to our mission.
02:59Prevention, advocacy,
03:00and research and under prevention
03:03we focus primarily on education
03:07and awareness and under education.
03:09We focus heavily on patients
03:11and caregivers and then we also
03:14focus on educating clinicians,
03:16and we're beefing that section
03:19of our website and materials up.
03:21And when I say clinicians,
03:24we've really focused over the last eight
03:26years on educating clinicians about the.
03:29Rapid rise of early age
03:32onset colorectal cancer,
03:34which will probably dig into later on
03:36this call if not circle back and I'll,
03:38I'll tell you some more about that myself,
03:40but it's a trend that we've been seeing.
03:42Unfortunately,
03:43grow over the last decade.
03:46Second prong of our mission is advocacy
03:49and we advocate for quality of life,
03:52fertility,
03:52preserving treatment for all patients,
03:54regardless of where they're treated,
03:56whether they're treated here at at Yale,
03:59in New Haven, or whether they're
04:00treated in a community Cancer Center.
04:03You know, anywhere else in the
04:04country or around the world.
04:05For that matter,
04:06we advocate for equal opportunity
04:09access to testing and screening,
04:11as well as treatment for all patients,
04:13and then also for assistance for caregivers.
04:17Because that assistance needs to
04:19needs to continue throughout the
04:21patients and their caregivers.
04:23Entire continuum of care.
04:24We call it even through end of life.
04:28And we do a large portion of that
04:30through our own event called the early
04:32age onset colorectal Cancer Summit,
04:34which we're now going into our 9th year,
04:36and that focuses largely largely
04:38again on the fact that this is a
04:40fact affecting younger and younger
04:42men and women throughout the world,
04:44and then finally the last problem
04:46of our mission is research.
04:48We we focus on primarily supporting
04:50young investigators who travel to
04:52conferences around the globe and
04:54support their efforts in moving the
04:57ball forward in translational research.
05:05See if I can move my OK, so for 2022,
05:08just very briefly we have some
05:10big hairy audacious goals or
05:12behaves as we like to call them.
05:14We want to raise enough money to.
05:18Essentially, provide 10,000 free
05:20screening test kits in underserved
05:23and underinsured and underinsured
05:25communities throughout the nation
05:27and we want to be able to tell 21
05:31million Americans ages 45 to 49.
05:33That 45 is the new 50.
05:39And one of the ways that we're doing
05:41that is through our major campaign
05:43called let's get screened.org.
05:45So if you actually visit
05:46that website is live.
05:48We started that campaign with Walgreens
05:50last year and we're continuing that.
05:52So we invite you to to
05:54go to letsgetscreen.org.
05:56There are materials there.
05:58There are social media kits there and
06:00we would love for you to be a part
06:02of that and just spread the word.
06:04And with that I will turn it back
06:06over to doctor, Court, Manske and.
06:08I look forward to hearing everything
06:11everyone has to say tonight.
06:12Thank you.
06:13Alright, thank you Cindy.
06:15I think nobody can oversell the
06:19the importance of colonoscopies
06:22and so I I hope during our program
06:26tonight you know we brought together
06:30a lot of experts on diagnosis and
06:34treatment but with colonoscopies
06:36this could be a preventable disease
06:39which is the hope for all of us.
06:43In the treatment of colon cancer,
06:44we know that it is a disease that takes,
06:48takes a team.
06:49It takes gastroenterologists
06:51and surgeons and radiation,
06:53oncologists and medical
06:55oncologists all working together.
06:57And so we designed a program tonight
07:01that that does just that and so
07:04we have a hammy to soccer from
07:08gastroenterology to give us words about.
07:12Screening and some syndromes.
07:14The newest advances in in surgical
07:17management with Doctor Ann
07:19Manju and Doctor Ahmed Khan A.
07:22Advances in radiation oncology with
07:24Doctor Kevin do and then taking us
07:27home advances in medical oncology with
07:30Doctor Justin Persico and so with that,
07:34I'd like to turn the baton
07:36over to Doctor Sachar.
07:41Thank you Jeremy.
07:41I'm just gonna share my slides.
07:49OK, so I'm going to be talking today
07:53about some about colorectal cancer
07:55screening and sort of some of the updates
07:58that were provided in the new USPSTF
08:01recommendations that were given in 2021.
08:05So colon cancer is important.
08:08It's the third leading cause of
08:10cancer death in the United States
08:11only lagging behind lung cancer,
08:13breast and prostate cancer in 2021 alone,
08:17approximately 53,000 people were
08:19estimated to pass away from this disease.
08:25So the important take away take
08:27away playing from all of this is
08:28that this cancer can be prevented,
08:30or it can be detected fairly early such
08:32that no one should have to die from it.
08:35This schematic that I have down over
08:37here primarily is just trying to show
08:39what the Natural History of colon
08:41cancer would be like without any sort of
08:44intervention that's made by screening.
08:45So you sort of start out with
08:47not having any sort of a lesion,
08:49and then you eventually grow
08:50something called a polyp,
08:52or what we call a precancerous lesion,
08:54or an adenoma.
08:55And eventually that if not intervened
08:57upon that could potentially
08:59become an undiagnosed cancer.
09:01So that would basically mean you would not
09:04yet exhibit any symptoms from this cancer,
09:06but it's in there,
09:08and eventually that will become
09:10something that would cause symptoms.
09:12So things like rectal bleeding,
09:14change in your bowel habits,
09:15weight loss, that kind of stuff,
09:18and again,
09:19if not intervened upon it can
09:21result in colorectal cancer death.
09:23So the point here is that screening effects.
09:26But can can mimic sort of the biological
09:28cycle of this cancer and sort of
09:31interventions can be made early so
09:33they can either be made in this
09:35stage which is at the adenoma stage,
09:37and it can really by doing so.
09:40You can really prevent cancer from forming.
09:42Or you could really intervene at this stage,
09:44which is essentially the preclinical
09:46stage and by doing so hopefully we found
09:49this cancer at a more treatable stage.
09:52So the incidence of mortality of
09:54colorectal cancer in the United States
09:56has decreased over the past decade.
09:57About 30% or so,
09:59and screening is most very clearly a
10:03very important contributor to this.
10:06So based on all this,
10:07the USPSTF gives a grade a
10:10recommendation for screening,
10:12and it says that the net benefit is
10:14substantial for patients if they
10:16get screened for colorectal cancer.
10:18So some other facts that are
10:20interesting is that even though
10:22this has been highly recommended,
10:24the national adherence to screening
10:26is not perfect,
10:27so approximately 26% of patients
10:29who are eligible for screening
10:31don't actually get screened.
10:33And as of 2018,
10:35about 31% of patients have not kept
10:37up to date with their screening.
10:39Now there's many factors that
10:43probably affect these estimates.
10:44Essentially,
10:45and ultimately probably provide
10:47barriers to screening,
10:49and we all know that there is
10:51sort of exacerbated in minorities
10:53and underserved populations,
10:54but there are issues related to
10:56access and how patients utilize this.
10:58These tests that have substantial effect
11:00on whether they get screened or not.
11:03Financial barriers are real,
11:04and luckily there has been a
11:06lot of movement in this and such
11:08that they have been removed.
11:09We're mostly removed for patients so
11:12that they really can't access screening.
11:14Ultimately,
11:14if your recommendation comes
11:16from your own doctor,
11:17it carries a lot of weight,
11:18and if there's some informed
11:20choices made alongside,
11:21it really can affect our rates of screening.
11:26So a few things, what do you need to
11:28know if you want to be screened as a
11:30few things related to your wrist level,
11:32what your own history is something about
11:34age a little bit about what you're kind of,
11:37medical conditions you have,
11:39and what your preferences.
11:40So when it comes to risk,
11:42we like to sort of divide patients
11:43up and say your average risk.
11:45Basically, if you have no signs of
11:47symptoms suggestive colorectal cancer.
11:49So basically no rectal bleeding,
11:50no pain in the belly,
11:52no change in your bowel habits,
11:53and if you basically don't have any of the.
11:55Risk factors that I'm going to
11:57just sort of talk about real quick.
11:59So if your increased risk,
12:02we really think that that's the kind
12:03of patient that has a first degree
12:06relative with colorectal cancer
12:07or basically high risk polyps.
12:08If you have two second degree
12:10relatives with the same,
12:11you would be considered an increased risk,
12:13and if you had a personal history
12:15of colon cancer or polyps,
12:17that would also be considered to
12:18be an increased risk patient.
12:20A high risk patient is anyone who has
12:21all sort of colitis or Crohn's disease,
12:23and this is simply related to the fact that.
12:26Chronic inflammation can give
12:28rise to colon cancer.
12:30And the highest risk patients are
12:32those who have confirmed or suspected
12:34genetic syndromes such as F,
12:35AP, or Lynch syndrome.
12:37There's many others,
12:38but those Lynch syndrome is probably
12:40the most common one that's inherited.
12:42I just wanted to mention that most
12:45cancers most colorectal cancer
12:46is not an inherited cancers,
12:48it's it's quite a small percentage overall.
12:52But when when you do have one
12:54of these inherited syndromes,
12:55it it's pretty important that
12:57we look at you fairly carefully
12:59and follow you very closely.
13:03So what tests are available for screening?
13:07The answer is a lot all right,
13:10so there's about 7 tests that
13:11are available for screening,
13:12and while this is great,
13:14it's also fairly confusing for patients
13:16to figure out what test they should use.
13:19So the bottom line here is that
13:22there's while there's multiple tests,
13:24they all have varying evidence
13:26that support their effectiveness,
13:27and there's really no head-to-head trial that
13:29suggests one test is better than the other,
13:31but they all have advantages and
13:34disadvantages now. Ultimately,
13:35the USPSTF has not ranked any of these.
13:38Tests so the bottom line here
13:40is the goal is to get screened,
13:43so any test is better than note,
13:45test to and ultimately whichever
13:47test you're going to do is the
13:49one that's best for you.
13:55Alright, so just a little bit
13:57about some of the tests that where
13:59we talking about the first one.
14:01Actually, I just want to go back.
14:03Sorry about that.
14:11Alright, so the very first group of
14:13tests that I want to talk about is
14:15something called stool based tests,
14:17so they sort of come up.
14:19There's three of them that you
14:21should probably know about,
14:22but ultimately the important thing
14:23to know here is that they need to be
14:26done every year or every three years,
14:28and I'll go over each one just to see
14:30which one is easiest for the patient to do.
14:33But in order to derive
14:35benefit from these tests,
14:37one needs to do them year after year
14:39in order for them to be effective.
14:42So in terms of the FOBT,
14:43which is a very common test that people
14:45used to do, and often at the office,
14:48although it's contrary to popular belief,
14:50is really not an office based test.
14:52You really do have to submit three
14:54separate samples and you have to have some
14:56sort of dietary restriction in order to
14:58prevent a false positive for this test,
15:00but it's an old test.
15:01It's a little bit out of vogue,
15:03but it is.
15:04It has been shown to be fairly
15:05effective in decreasing colorectal
15:07cancer related mortality.
15:09You don't need a bowel prep or any sort
15:10of sedation for this. It's fairly.
15:12Easy to use and inexpensive.
15:15The other test that most people may have
15:16heard about is something called the Fit test,
15:18which is a fecal immuno histochemical test.
15:21It's basically detecting intact
15:23human hemoglobin in stool and
15:25it's very easy to use.
15:27You really just only have
15:28to submit a single specimen.
15:29It's pretty inexpensive as well.
15:32Now,
15:32some people may have heard about
15:34something called the Cola Guard,
15:35which is a fit DNA test and what
15:37it does is it takes the fit test
15:39which is looking at the human
15:41hemoglobin and it combines it with
15:43another test that looks for altered
15:46DNA biomarkers and cells that shed
15:48that are shed in this in stool.
15:51It's probably more sensitive than
15:52the fit test in itself in detecting
15:55colon cancer if it's used for,
15:57you know every one test that you do,
15:59but it also is gives rise to a lot of false.
16:02Positives and every time there is a
16:04false positive it results in another test,
16:07often a colonoscopy,
16:08and so that is something to keep
16:11in mind as well.
16:12It is a single sample test,
16:14but usually you have to submit an
16:16entire bowel movement for this and it
16:17does not require a bowel prep or sedation.
16:19It is fairly expensive though.
16:23The other set of tests that are used are
16:26something called visualization test,
16:27so you know you have the stool
16:29based tests and they do all kinds
16:30of things to see if there's any
16:32sort of markers for colon cancer,
16:33but these are visual tests.
16:35We're really looking with our eyes
16:37to see if there's anything wrong or
16:39anything that we can intervene on,
16:41so the first one that I'll talk
16:43about is called a city colon ography
16:45as the name source suggests,
16:47it's sort of a CT scan of a patient,
16:50and what they're really doing is
16:51they're looking inside the colon.
16:53Of a patient where they pump a little bit
16:56of air and they look for either cancer
16:58or really some polyps or adenomas which
17:01are precursor lesions for colon cancer.
17:03So this test does require a bowel prep
17:05but it doesn't require any anesthesia and
17:08one of the disadvantages or advantages
17:10whichever way you want to look at this is
17:13that you can sometimes find things that
17:15you may or may not want to know about.
17:17So sometimes it's useful if you find
17:19something that's not that that that
17:21could be life threatening like.
17:23Aneurysm or something like that.
17:25But sometimes you find things that you
17:26really don't probably need to intervene on,
17:28and probably needs to
17:30unnecessary testing there.
17:31Is this concern about
17:33radiation exposure as well,
17:34but it's really related to repeated exams,
17:36if anything.
17:37So typically what will happen is this is
17:40your colon and see there's a polyp in here.
17:43One would insert a rubber tube and
17:45put some air in there so that this
17:47could be clearly seen when the
17:49patient goes through a cat scanner.
17:53Now colonoscopy, this is a far and
17:56away the most popular test in the
17:59United States and it what it really
18:02involves is this flexible tube with a
18:04camera at the end of it to be inserted
18:06through your ****** and it kind of
18:08goes all the way through your colon
18:09and this sort of this picture kind of
18:11shows what a normal colon looks like.
18:13A very careful withdrawal is done
18:15in which all all the parts of
18:17your colon I looked at carefully,
18:19and if there was a growth like a polyp,
18:22the good thing about this test is that.
18:24We're we're able to intervene right then
18:26and there and sort of remove this polo.
18:29They can see sort of a lasso being
18:31put around this polyp so that
18:33it can be transacted.
18:34So in some ways,
18:35while this looks for cancer
18:37and it's a screening test,
18:39it also prevents cancer by
18:42removing precursor lesions.
18:44And sometimes it can also be
18:46used to remove early cancers,
18:49and it prevents the need for surgery.
18:55So again, colonoscopy is probably
18:57the only test that really helps with
19:00prevention as well as early detection.
19:02And it is associated with less
19:04frequent screening intervals.
19:06It's somewhere in the order of 10 years.
19:07If you really don't have anything in
19:09your colon and that requires follow up,
19:12although it does require a bowel preparation,
19:14there's subsidization involved in you know,
19:16inconveniences like being transported
19:18to and forth from the Endo unit.
19:22The last one is something called
19:24a flexible sigmoid osca P,
19:25which basically is just evaluating
19:26the left side of the colon,
19:28and modeling suggests that its
19:31benefit it's probably less beneficial
19:33if used alone when compared to the
19:36other screening scrap strategies,
19:38except if you combine it with a fit
19:40test which has to be done every year.
19:42And ultimately this test is just a
19:44little less popular in the United
19:46States and probably not used as
19:48frequently as colonoscopies and
19:50other stool based tests are.
19:52I just wanted to show everyone.
19:53What it means to sort of screen
19:56and what benefit this really has?
19:58So this really shows us what,
20:00how many life years are gained if one is
20:03to engage in any sort of screening strategy.
20:06So this kind of lists all the
20:08different tests that you can do,
20:09and this kind of shows how
20:10well it performs for patients.
20:12So this is a life years gained per
20:14thousand patients who are screened,
20:15and you can see that more or
20:17less they perform the same.
20:21This is about how many cancer deaths
20:24diverted for 1000 patients were screened.
20:27And then this kind of shows harms,
20:29and obviously the harms are
20:30mostly related to a colonoscopy,
20:32because that's that's pretty much the
20:34only one that involves a procedure and
20:36any sort of harm that's associated
20:38with the stool based test is usually
20:40when they turn positive and they end
20:42up having to require colonoscopy,
20:43but relatively speaking,
20:45if you look at the numbers of how many years,
20:48how many deaths you revert versus
20:51how many patients you cause harm
20:53for is fairly small.
20:55So the question here is for an
20:57average risk patient when you
20:59start and when you stop screening.
21:00So it's fairly clear from all the
21:03evidence that's available over the years
21:05that if you're between ages of 50 and 75,
21:08there's a clear reduction in death
21:11related to colon cancer if your screen.
21:14If you're over age 75,
21:16though, that's this.
21:17This benefit is is declined.
21:20It's not terribly declined,
21:22but it's really probably not as useful
21:25as when you're between 50 to 75.
21:29I do want to emphasize that if
21:31you've not been screened before,
21:33it's probably best applicable to you.
21:36So if you have had colonoscopies age 50,
21:39age 60, and then again it's 70,
21:41it probably is not very beneficial to
21:43keep doing it from there on forward.
21:45However, if you've never had any
21:47sort of test before, this is probably
21:49a worthwhile testing gauging,
21:50provided you're in good health.
21:53And then for age 86 and over,
21:55it's a pretty clear no,
21:57because the benefit is very
21:59minimal at that point.
22:01Presumably you have other diseases
22:03that may be taking center stage
22:05in your life at that point.
22:08Now some of the harms that
22:10we need to talk about,
22:11because whenever we think about screening,
22:13we think about risks and then
22:15we think about benefits.
22:16So we just talked about the benefits part.
22:17But what are the risks really like?
22:20I mentioned before,
22:21they're largely related to the colonoscopy,
22:23and it's either when you do the
22:25primary exam or when you follow up a
22:27stool based test or another test that
22:29shows a positive finding and what we
22:32know is that if you're between age 50 and 75,
22:34the risk is rather small.
22:36And as you keep aging.
22:38The risk,
22:38while it's small to moderate it,
22:40does increase ultimately.
22:44So this is ultimately what the USPSTF said.
22:47As of 2016 they were like for everybody,
22:4950 to 75.
22:50Go ahead and screen them for 76 to 85.
22:54Be selective.
22:55How about discuss with your doctor
22:57and decide whether this is worthwhile,
22:59and then if you're 86 and over,
23:01the idea is not to screen.
23:02It's a great day recommendation.
23:05So between 2016 and 2021 really the
23:08question that was raised was whether
23:10we should screen earlier than age 50.
23:14And this basically came about
23:16because we realized that colon cancer
23:18incidence and mortality was decreasing
23:20for patients who were 50 and over.
23:23But it was increasing for patients
23:25who were less than 50.
23:27And really where it was most substantial
23:31was in the age group between 40 to 49.
23:35Why this increase occurred?
23:36I'm not sure we can fully answer this.
23:39I mean whether it's related to
23:41your diet or a like body, habitus,
23:43smoking status.
23:44It's not entirely clear what has
23:46LED up to this sort of trend.
23:49But ultimately,
23:50after all the information was collated,
23:53initially started with the
23:54American Cancer Society,
23:55but eventually with the USPS TF it
23:57has been made fairly clear that for
24:00patients who were aged 45 to 49,
24:02we should be screening them using
24:04the straight steam strategies
24:05that I just mentioned.
24:06And while this is a Grade B recommendation,
24:08still pretty solid recommendation
24:11to carry forward.
24:13Now how do they come to this conclusion?
24:15I won't burden anybody with this,
24:17but ultimately it's because they
24:19updated the predictive modeling
24:21that is involved in trying to come
24:23up with these recommendations.
24:24It's also clear that if you if you
24:27save patients at age 45 forward,
24:29there's a lot of years that you're saving
24:32for this patient in their lifetime,
24:33so it really does have a huge
24:37benefit to that patient.
24:38So we do know that if you're younger,
24:40you have a heavy burden of disease,
24:42and we do know that this.
24:43This rise that's occurring in
24:45colorectal cancer is not artifactual,
24:47it's actually real.
24:48And so if you start screening at 45,
24:51hopefully you will benefit all those
24:53patients who are between age 50 and
24:5554 because we all know that nobody
24:57usually starts right at 50 on the dot,
24:59so it gives them a little bit of leeway
25:02to make sure that they come on time,
25:04and then we already know that certain
25:07certain populations were already
25:08suggested to start a little bit early,
25:10like the African Americans in particular.
25:13So this.
25:14Age starting at 45 encompasses
25:16nearly everybody at this point.
25:19So according to the American
25:20Cancer Society and the USPSTF,
25:22we have a green light to go ahead
25:25and start screening at age 45.
25:29Now this just sort of.
25:31I just wanted to sort of talk a
25:34little bit about patients who may
25:36not be as well as somebody who comes
25:39into your office and say they have
25:43a pretty devastating disease like
25:45cirrhosis in which they're fair.
25:47They're not doing very well,
25:48and then the question here would be,
25:50would you screen this patient and
25:53would would one recommend that the
25:55question really is the answer here
25:56is not really so if you have a life
25:59expectancy less than five years.
26:01It's probably not worthwhile to
26:03undergo screening so that just
26:04comes with a small caveat there.
26:06While we encourage everybody to get screened,
26:08it really should be an individual decision.
26:11If these sorts of things are at play.
26:15I just wanted to mention that
26:17patients were at increased risk
26:19which we defined as you know your
26:22family history for colon cancer.
26:24How do we screen these patients?
26:26So like I mentioned,
26:27if you have a first degree relative
26:29who has an age that's over 60,
26:32you can really use any screening modality,
26:34but you must start at age 40 and you
26:36would follow the intervals as per whatever
26:39your test each test suggests to do so,
26:41like for a fit.
26:42It would be every year for
26:43colonoscopy 10 years.
26:45Depends on what the findings are.
26:48If you have two second degree relatives,
26:50you sort of follow the same thing again,
26:52but if you have a first degree
26:54relative whose age is less than 60,
26:56really the only test recommended
26:58here is a colonoscopy and it's just
27:00because you're you're considered
27:02to be a truly high risk and you
27:04probably should start at age 40
27:06or 10 years before the youngest
27:08case was diagnosed in your family.
27:10You and you should be repeating this
27:12test every five years just to define
27:14what a first degree relative is.
27:16That's your mom and your dad,
27:19your brother, your sister, your kids.
27:21Your second degree is Grandma,
27:23Grandpa cousins, aunts,
27:24that kind of stuff.
27:28Now what do you do with patients
27:29who are high and highest risk?
27:31Well, these are the patients
27:32who have genetic syndromes and
27:34or inflammatory bowel disease.
27:36And really the answer probably here
27:37is to they should probably be going
27:39to and a center that has experience
27:41with managing these patients because
27:43they're probably best served
27:44in these sorts of institutions.
27:47So in summary, the mortality from
27:49colon cancer can be prevented.
27:51There's not enough patients who
27:53are getting screened currently.
27:54There are many strategies that are available,
27:56and the goal ultimately is to screen
27:58them by any method that they prefer.
28:01So any test is better than no test,
28:03and colonoscopy does carry that extra
28:07benefit of being preventative in as as
28:11well as trying to find early cancer,
28:14and that's what I have for you today.
28:18Thank you so much.
28:19I mean that was a great presentation
28:21really emphasizing the all the
28:23different options that are available
28:25to get the colon cancer screening
28:28done to not seeing any questions
28:31in the chat and to try to keep
28:33us on a reasonable schedule,
28:35let's we'll move on to the the next talks,
28:38which is a combined effort between
28:41Doctor and Manju and doctor Amit Khanna.
28:43So Doctor Manju will let you start.
28:48Alright, let me go ahead and share my screen.
28:59Alright, hi, good evening my name
29:01is Anne Manju and I'm an assistant
29:04professor of surgery at Yale,
29:06New Haven Hospital,
29:07and I specialize in colon and rectal surgery.
29:09And tonight, myself,
29:10along with Doctor Connor,
29:11gonna speak to briefly about some
29:14advances and innovations in the surgical
29:17management of colon and rectal cancer.
29:20I like to work with pictures,
29:21so the first thing people ask about when
29:24they are diagnosed with the new colorectal
29:26cancer is about what surgery are we gonna do?
29:29How much colon are we going to take out and
29:32and how are we going to actually do it?
29:34So to answer that question,
29:36sort of requires knowing maybe where
29:38the cancer is and then additionally,
29:40as we just talked about.
29:41Maybe if there's an underlying
29:43genetic disorder that might actually
29:44put the entire colon at risk,
29:46we may not just take one portion
29:47of the colon with the cancer,
29:48but we may have to take more to prevent
29:50the risk of future cancers and so.
29:52Here we see that the surgery to
29:54remove colon cancer has a bunch
29:56of different names and those are
29:57names that the specialist might say,
29:59but those just really mean that we're
30:01going to take out the portion of your
30:03colon that actually contains the lesion,
30:05and in doing so,
30:06we want to take good healthy
30:08colon on both sides of it.
30:10We also take the blood vessels
30:12that supply that part of the colon,
30:13and with that comes the fat and
30:15all the lymph nodes.
30:17That combination of tissue basically
30:19allows the pathologists to really
30:21get all the detailed information.
30:23That they need to know about
30:24what your tumor was.
30:25If it has spread anywhere else
30:27into the lymph nodes and you know
30:28allow us to know that we've gotten
30:30everything out cleanly.
30:32And so how much we takes at the pen,
30:34how much we take out in the operating
30:36room really depends on the exact location
30:38and what blood vessel territory is serving.
30:40That portion of the colon,
30:41and these are just some illustrations.
30:43Historically,
30:43when we think about surgery,
30:45we think about we call traditional
30:47open surgery that surgery whereby
30:48we go to the operating room.
30:50We make a vertical up and down
30:52incision in your abdomen.
30:53We open the abdomen,
30:54we take out the area that we
30:56need to take out.
30:57We put the two ends of the colon
30:58back together and then we close
31:00the abdomen of either stitches.
31:01Or sometimes you may have
31:03seen surgical staples.
31:05It's very effective,
31:05but the recovery from that can be
31:07a little bit painful because you do
31:09have a large incision that runs up
31:11and down the middle of your abdomen.
31:13And also there's a risk of forming
31:15a hernia afterwards and that the
31:17pain can often slow peoples return
31:20back to their normal activities
31:21and in ways of life.
31:23So moving on in the early to mid 1980s,
31:27the field of general surgery
31:29from which colon rectal
31:30surgery is apart, started taking
31:32cues from our colleagues in the
31:33fields of urology and gynecology,
31:35which had started this new keyhole
31:37or minimally invasive surgery.
31:39We refer to that now more
31:42often as laparoscopic surgery.
31:44Laparoscopic surgery allows us to
31:46make small incisions in the abdomen,
31:49put some, get some gas into the abdomen.
31:51We usually use carbon dioxide.
31:53Blow it up and then use a very tiny
31:55precise camera as well as long
31:57instruments which are on a straight
31:58stick and we can now do that same
32:01surgery that we had to perform previously
32:03through a large incision through a
32:04bunch of small incisions which are
32:06about the size of my thumbnail or
32:08a little less than a centimeter.
32:11Usually to make that connection we
32:12would still have to make a small
32:14incision in the middle of the abdomen
32:16to pull out the intestine and put the
32:17two ends back together and take out
32:19that last portion once we freed it up.
32:21But this is really a really
32:23much smaller incision.
32:24People started to use this first
32:26for gallbladder surgery and then for
32:28appendix surgery and eventually the
32:30field of colon and rectal surgery
32:32moved heavily into minimally invasive
32:34surgery and this really sort of
32:36revolutionized people's recovery from
32:38having a portion of their colon removed.
32:41Just like our iPhones continue to
32:43get more and more advanced with each
32:46iteration of surgery continues to
32:49advance and you may have seen ads
32:52or pictures about robotic surgery
32:54and so robotic surgery is really
32:57just a further refinement of.
32:59Laparoscopic surgery.
33:00The robot doesn't actually
33:02do any operating on its own,
33:04but what we see here on the left
33:06hand side of the screen is the the
33:08Davinci Intuitive Surgical robot and
33:10what it does is it actually holds the
33:13instruments and in doing so you have
33:15now 4 operative arms for a single surgeon,
33:17whereas if I.
33:19Go back to the prior slide.
33:20You can see that each surgeon we have,
33:22we've got two hands.
33:22At most you can hold two instruments where
33:24you could hold a camera on an instrument.
33:27So one person you really need two people
33:29in any operation to do a colon operation.
33:32Now when we talk about the surgical robot,
33:36we there's actually four arms and
33:38a single surgeon controls them.
33:39The way the surgeon controls the robot
33:41is you actually go about 10 feet
33:42away from the patient in the operating room,
33:44and you sit down at this surgical
33:46console that you see here on the
33:48right hand side of the screen,
33:49the console is sort of very ergonomic
33:51and adjust to each surgeon and saves it,
33:53just like your car might save your
33:55seat positions when you get in,
33:57and when you sit down,
33:58you're looking into this console that
33:59you see here on the right is actually
34:01a pair of goggles that you look into,
34:03and now you have a 10X magnification.
34:05Of your operating field and not only that,
34:08it's in three dimensions because
34:09the camera that the robot
34:11uses actually has two parallel
34:12cameras in line with each other,
34:14so that gives you what we call a depth
34:15of field or allows you to see him.
34:17What looks like 3 dimensions without actually
34:19wearing any three dimensional goggles.
34:21The view is incredibly
34:23sharp and incredibly bright,
34:25so that's one advantage here is that
34:27we now have an incredibly stable
34:29platform that doesn't have any rotation,
34:31or you're not dealing with
34:32a human holding instrument.
34:33You're dealing with a very precise robot.
34:35The second thing that's really
34:37neat are the actual instruments.
34:39These instruments that the robot is holding.
34:42They are actually far more advanced
34:43than even our most advanced
34:45current laparoscopic instruments,
34:47and the reason for that is that they
34:49have wrists just like a human hand,
34:51and so they can actually articulate
34:53with more degrees of freedom
34:55than the human hand actually can.
34:57This allows them to get into
34:59very small places,
35:00and also you can manually scale
35:01how precise the movement is so that
35:03you can actually make very tiny,
35:05very precise movements.
35:06In very tight areas,
35:08and this allows us to do things
35:10like very carefully peel tumors
35:11off of large blood vessels,
35:12something that might have required
35:14you know that might have been
35:16a little bit more tedious in a
35:17laparoscopic situation somewhere
35:18where we have much better control
35:20because of our superior visualization.
35:22This is particularly helpful when
35:24we talk about rectal cancer surgery
35:27because the ability to go deep into
35:30the pelvis to find low rectal cancer
35:32tumors and actually spare your
35:34sphincter complex, which is you know,
35:36means that.
35:37We can eventually render you without any
35:39sort of colostomy bag is a wonderful thing.
35:42Previously low rectal cancers,
35:43a lot of people ended up with a
35:46permanent colostomy bag because of
35:48robotic surgery and our ability
35:49to get very low into the pelvis.
35:51We're actually able to restore people to
35:54complete continence much more regularly now.
35:58And that's,
35:58I think one of the huge benefits of this.
36:00A third benefit is really in a small detail,
36:03but it's the fact that we're
36:05actually able to put the two ends
36:06of the colon back together.
36:08Inside of your body without having
36:10to pull anything out and why that
36:12is good and useful is that then
36:13allows us to take out the part of
36:15the colon that had the cancer through
36:17an incision like a low C-section
36:19incision or what we call a Pfannenstiel
36:22incision that's actually in the bikini area.
36:24This is not only good from a
36:26cosmetic standpoint,
36:26but it's really good because these
36:28incisions are much less painful.
36:30People recover from them much
36:32more quickly and they have a much
36:34lower risk of hernia formation.
36:36The next two slides I'm going to
36:37show you are just one other really.
36:39Neat feature a safety feature of the robot.
36:41That's something that's great that
36:43has really also adjusting the way
36:46we think about certain parts of
36:48robotic colorectal surgery.
36:49In the 1950s,
36:51a fluorescent dye called in
36:53designing green was identified
36:54and it was actually used
36:56in some cardiac studies.
36:57It's a non toxic dye that
37:00fluoresce is green when exposed
37:03to infrared wavelengths of light,
37:05and so intuitive thinking that this
37:07was the the surgical company think
37:10that this was actually could be a
37:12very useful Diane was being used
37:14in different areas of surgeries.
37:15People were starting to look at perfusion,
37:17this die lights up,
37:18blood vessels actually incorporated
37:20infrared technology into the
37:21robotic camera so that with the
37:22touch of your finger you can act.
37:24Actually toggle the screen that
37:25you look at in your head piece
37:28to see this infrared view.
37:29So this actually comes in handy
37:31in two really critical parts of
37:32colon and rectal surgery operation.
37:34So I'm gonna tell you a little bit
37:36about this picture we see here on the
37:37right hand side of the screen we see
37:39the colon in one of our operating
37:41instruments here on the right,
37:42and the colon is we're looking
37:43at where are we going to divide
37:45it to make our division point to
37:47take out the part with the cancer?
37:48The part with the cancer is off to
37:50the right hand side of the screen.
37:51We don't see the marking.
37:52It's a little further off if we're looking.
37:54Here at the screen itself,
37:56right beyond the tip of the instrument,
37:57we'll see.
37:58Maybe there's a faint difference
37:59in the color of the colon.
38:00Maybe it's not quite as pink as the
38:02colon is right here, but you know,
38:04we would be looking at it to try this side.
38:06Is this area 'cause we've already taken
38:08the blood supply to this part of the colon,
38:09and we want to make a healthy connection
38:11between the two remaining parts of the colon
38:13once we take out the part with the tumor.
38:15So when we inject the dye and we
38:17flipped our infrared imaging,
38:19it actually glows bright,
38:20clean,
38:21and so right here you can see
38:22a line where the colon is very,
38:24very green.
38:25All the tissues are candy,
38:26apple green and then the other side
38:28of it is very dim and this actually
38:30allows us to very safely and accurately
38:33divide the colon inside the body.
38:35With our surgical staplers and know
38:37that we are dividing at a point
38:39which is very healthy and it's
38:41going to help us to put the two
38:43ends back together in a Safeway.
38:45One other way that we use it and
38:47this is just a brief one again on
38:49the right hand side is the view that
38:50the surgeon would see if you were
38:52doing open or laparoscopic surgery
38:53and on the left hand view we see
38:55a structure that's highlighted in
38:56green here that you can't really
38:58even appreciate at all on the right
38:59hand side of the screen.
39:01This little tube that's been lit
39:02up here on the left hand side of
39:04the screen is actually the ureter.
39:05That's a little tiny straw light
39:07structure that connects your kidneys
39:09which make urine down to your bladder well.
39:12The ureter runs underneath
39:13the colon and so it's often.
39:15In the field of our operations,
39:17especially if someone had radiation treatment
39:19or has had prior abdominal surgeries,
39:21it could get pulled into our operative field,
39:24and that's something that we'd like to avoid.
39:25So we're actually able to inject the
39:28ureter with this fluorescent dye.
39:29It stays and glows bright green
39:31throughout our entire operation.
39:33Sort of like I call it like a
39:35landing strip at the airport,
39:36and shows us, hey, this is down here,
39:38and it allows us to not
39:39to act to even expose it.
39:40We can actually just push it down with
39:42its normal tissue layers of covering.
39:44Normally in past we would have to
39:45actually dissect out the year to
39:47make sure we had it before we fired.
39:48Any staples now?
39:49We can actually see it through
39:51tissue and know that it's safe
39:52and secure and out of our way.
39:54So those are some of the advances in
39:57actual technical side of surgery,
39:59and doctor Connor is going to go on and
40:01mint talk more about our care pathways,
40:03but something I want to talk about
40:05briefly that you might have heard of
40:06is enhanced recovery after surgery.
40:09So we've made surgery less invasive.
40:12But how
40:13can we get people home more quickly
40:16and get people back to baseline sooner
40:19after you've had a colon surgery and so.
40:22The pathway that involves everyone
40:24from our pre operative team in
40:27the clinic to our anesthesia.
40:29Colleagues in nurses in the operating
40:31room as well as the surgeons as
40:33well as our nurses on the floor
40:35after surgery is what this is.
40:36This eras pathway and what it is is the
40:39goal is to set your body back to its
40:42normal status as quickly as possible.
40:44One of the ways we do this is by letting
40:46people drink clear liquids all the way
40:48up almost until the time of surgery
40:50before we said you'd have to fast
40:51for hours and hours before surgery.
40:53Now we know that you can.
40:54Actually drink high carbohydrate
40:55drinks even four hours before surgery,
40:58which means your body has less stress
40:59when you're in the operating room.
41:01By having less stress in the operating room,
41:03your body is actually able to start valve
41:06function back up sooner after surgery.
41:08When we're in the operating room,
41:10we now work with our anesthesia colleagues.
41:12They work on multi modality pain control,
41:15which means we try to avoid opiate pain
41:18medication both in the operating room
41:20and afterwards by minimizing opiates the
41:22intestines wake up faster from surgery and.
41:25When they wake up faster,
41:26we get you out of the hospital faster
41:28and so our colleagues in the operating
41:30room use less opiates and they also
41:32minimize the amount of fluids and then
41:34we get to after surgery and what we like
41:37to do is we start you eating right away.
41:39Sometimes people still come and say oh so
41:40I'm not gonna be eating for several days.
41:42I'm like, no, you're going to start
41:44drinking liquids a few hours after surgery.
41:46We'd like to stimulate the
41:48GI tract again to function.
41:49We like to take out excess Ivs and drains.
41:52As soon as we can.
41:53After surgery,
41:53we'd like to take the Foley out.
41:55You know,
41:55if not the night of the day,
41:57the morning after most surgeries that
41:59people get on their feet more quickly,
42:01we have nurses that are ready to
42:03help patients walk in the halls
42:04of the hospital after surgery.
42:06Even sit in a chair the night of surgery.
42:08All of these things serve to bring our
42:11body systems back to normal more quickly,
42:14and the sooner the body feels
42:15like we're back to normal,
42:16the sooner that we feel back to normal
42:18and have return of function and get back
42:21home and get back on with living our lives.
42:24So it's just a little bit about
42:25more of the mechanical side,
42:27and now I'm going to turn it
42:28over to my colleague Dr.
42:29Khanna to talk to you about some
42:31of the bigger picture sides of of
42:33how we integrate within the system.
42:37Just stop sharing.
42:44Alright.
42:49Doctor Connor, do you wanna go
42:50right to your talk and then?
42:53We can address any that'd
42:54be greatly after that. Sure,
42:56I'm gonna try to share my screen here.
43:02Let's see if we can get this to work.
43:13Chedoke
43:27alright, I hope everybody can see that now.
43:29It'll help me know that everybody
43:31can see the screen there.
43:33You guys think great so
43:38my name is Amit Khanna.
43:40I'm one of the colorectal surgeons at Yale.
43:42I'm mainly based out of the Bridgeport,
43:45Fairfield region and really a pleasure to
43:47be here with everyone tonight and thanks
43:50so much to everyone for coming online
43:55for for a talk about colorectal cancer.
43:59So I think Doctor Manji
44:01did an incredible job of.
44:03Showing some of the incredible
44:06innovations that we have in
44:09colorectal cancer surgery today and.
44:14What we can do now?
44:17Is use robots as and pointed out
44:19and now our hands are attached to
44:22to robots and we guide robots with
44:26precision in a way that we really
44:29couldn't do years ago and I think
44:31Doctor Manji did a great job of
44:34that and so you know this is just a.
44:38A the tip of what we're doing in
44:41in terms of technology and how
44:44technology has really changed the
44:46way our patients recover and the
44:49outcomes that we get for our patients.
44:50For colorectal cancer surgery.
44:54And and what we see has changed and
44:56and and I think Doctor Munger really
44:58did a great job at showing you,
45:01you know,
45:02some different applications of
45:03technology about how we see the
45:05disease and how we're able to
45:07do better by seeing better using
45:10these technological advances.
45:11But I thought I would talk a little
45:14bit about not only our view of
45:16the technology and how we improve
45:19each individual patient,
45:20but how we improve the care of our
45:23patients as a whole as a group.
45:25And I think you know when I was a resident,
45:30one of the common sayings was
45:33from my mentors.
45:35Was you know the surgeon is
45:37the captain of the ship?
45:39And you know that was sort of the
45:41the mantra that that that you know we
45:43were to guide that the care of the
45:45patient and that we were the captain.
45:47And I think Viewpoint has has
45:50largely changed about that,
45:52and that I think now we really
45:56view what we do as a team effort.
46:00And so instead of you know how
46:03do surgeons care about care for
46:06colorectal cancer patients.
46:07It's largely become.
46:09How do we care with the emphasis on we?
46:13It's a team based approach to
46:16colorectal cancer care,
46:17and I think that's really to me the
46:20greatest innovation over the last.
46:22You know,
46:23many years is how integrated the
46:25delivery of our care is for cancer patients,
46:29and it's a journey.
46:31That has many team members impacting
46:35the care journey along the way and
46:38and it becomes an integrated pathway
46:41of multiple different specialties.
46:44And also non clinical support.
46:49And you know,
46:50I love this quote from Michael Jordan.
46:52And you know, talent wins games.
46:55But teamwork and intelligence
46:57wins championships.
46:58And that's the same idea when we talk
47:01about taking care of rectal cancer
47:03and colon cancer and anal cancer.
47:06Is that, you know,
47:08individual outcomes are wonderful.
47:09Individual talent is great.
47:11We have incredibly talented surgeons
47:13and oncologists and radiation
47:15oncologists and other caregivers.
47:19That bring incredible specialty
47:20experience to the table,
47:22but we do so much better when
47:24we integrate all that care
47:25into a team based approach.
47:30And so how do we do that in real
47:33time with individual patients?
47:35Well, we have brought together incredible
47:38talent in terms of our specialists
47:41and we work to coordinate that care.
47:44We use digital platforms so that we
47:46can not only communicate between
47:48providers but also with patients
47:50so that access is an incredibly
47:52important thing that our patients have.
47:54And they're not leaving a message.
47:57And not getting calls back on all those
48:00calls are documented and we have support
48:02education that we can provide those
48:05patients using Internet platforms,
48:07whether that's through the EMR like EPIC,
48:10which we use here at Yale,
48:12but also other platforms we've employed
48:15a lot of advanced clinical support staff
48:19and that includes physician assistants,
48:23highly specialized nurse practitioners
48:25and other support staff.
48:28That really provide a ton of
48:30clinical support to our patients as
48:32they're growing through a really
48:34difficult time in their lives.
48:36We also then focus on,
48:38you know,
48:38trying to bring all the care to be
48:40centered around patients rather than
48:43patients running to different sites
48:45for tests and labs and imaging.
48:47We try to bring all of that to
48:49the patient at a single site,
48:50and that includes genetic counseling
48:53that includes support groups
48:54that also includes an incredible
48:57integrated patient centered.
48:59Support system that includes massage therapy,
49:03Tai chi, acupuncture,
49:04all centered at the Trumbull location
49:07and I think you know all of those
49:09things together in including the
49:11meditation garden that we have in
49:12the center of our trouble location
49:14which I have to admit.
49:15I've I've sat in front of that I'll
49:17waterfall a couple times on a couple
49:19hard days so I can tell you I've found
49:22peace there and I I know that many
49:25of our patients really enjoy that part of.
49:29Of their care journey that that it's a.
49:32It's a place of support
49:34and then we talk about.
49:35Well,
49:35how do we improve quality and how
49:37do we drive improvements in the
49:39delivery of what we're doing and
49:42and I can tell you that it happens
49:44both at the hospital level and it
49:47also happens as an entire system.
49:49So when we talk about,
49:50say,
49:51Bridgeport hospital in New Haven
49:53Hospital or Greenwich Hospital,
49:54we're looking at the data to see
49:57how we're doing.
49:59And we're taking that data and then
50:01comparing that to the standards
50:03that are being set nationally,
50:05and also that our internal standards to
50:09try to achieve as a health system to
50:13truly be world class, which is our goal.
50:18We have lots of groups where
50:20we work together.
50:21We actually,
50:21you know colon and rectal surgeons,
50:23oral surgeons who do colon and rectal
50:25surgery come together and we kind of
50:27talk about our best practices and
50:29how we can improve and we coach each
50:31other in a very collegial manner.
50:33We use tumor boards.
50:35We focus on building standardized
50:37systems that will apply to all of
50:39our hospitals in every patient
50:41that comes through our system.
50:43To maximize their outcomes,
50:44we also use different innovative
50:46approaches that are being done at
50:48different parts of our health system.
50:49And then we integrate.
50:50Get into the practice at
50:52various delivery networks,
50:53whether that's in the Bridgeport region,
50:55the Fairfield Region,
50:56New Haven, or other markets,
50:58and I think the other thing that's
51:00really wonderful about having a
51:02team based approach to colorectal
51:04cancer is that we can approach
51:06challenging low volume cases,
51:07so that's recurrent colon cancer.
51:09Recurrent rectal cancer.
51:12Specialized recurrent anal cancer,
51:14so we're able to manage very
51:16complex situations because we
51:18just have a big team and a lot of
51:21infrastructure and a lot of depth
51:22to the talent and the types of
51:24technology that we have here at Yale.
51:26We're very lucky that we can serve
51:28that population of patients and then
51:30the last thing I would say is that.
51:32You know,
51:34we've tried to build programs out into
51:37the communities of where our patients live,
51:39and so that we're more
51:41accessible to our patients,
51:42and certainly patients that travel.
51:46During their cancer care,
51:48it's a major barrier,
51:49and so we want to lower those barriers
51:51to as low as possible so that we
51:54can make directed appointments and
51:55where patients live and in their
51:58communities and also bring specialists
52:00all around the patient so that we
52:02can deliver multidisciplinary care,
52:04not just your surgeon,
52:06but your oncologist,
52:07your radiologist,
52:08your pathologist,
52:09all coming to you around the
52:11same center and you're going to
52:13meet Doctor Prisco and Doctor
52:15Do who I work very closely with.
52:17And then obviously I'm keeping in
52:19communication with our patients
52:21primary care doctors,
52:22their gastroenterologists,
52:23and making sure that they are
52:26looped in on what we're doing.
52:28And most importantly,
52:29I think that the biggest innovation,
52:32I think,
52:32has been our ability to come
52:34together as a team of providers to
52:37be centered around our patients.
52:39Whether it's our rectal cancer
52:41multidisciplinary program,
52:42which you'll hear about,
52:43which is one of the only ones in
52:45the Yale New Haven Health system.
52:47And we're extremely excited to be
52:50able to offer these types of services
52:52to our patients in the Community.
52:54And that's really all I have to say.
52:58And thank you again for the
52:59opportunity to be here tonight and
53:01I'm just very privileged to be around
53:03so many great providers tonight.
53:04So thank you so much.
53:09Thank you Amit. Thank you and
53:11those were both fantastic talks.
53:15I just want to encourage if anyone in
53:17the audience has any questions that
53:18they wanted to direct to or do any
53:21of the panelists just do it either
53:22through the chat or through the the Q&amp;A.
53:27I thought I would just take 2
53:29minutes just to ask a question.
53:31One of the most feared outcomes of
53:34surgery for colon or rectal cancer
53:37is the need for an ostomy and I was.
53:40I was hoping you could answer one how
53:42you make that decision of who needs
53:44one and then as importantly what is
53:47what's the support that's given to a
53:49patient who needs an ostomy during
53:51either before surgery after surgery
53:53to help reduce some of that anxiety.
53:59I can speak a little bit to that,
54:01and certainly discussion of a stoma really
54:03is one of those points of high stress.
54:06So at one of the things that we do
54:09have or what we call wound ostomy
54:11care nurses and was one of the really
54:13good strengths of our entire system,
54:15we have pre operative coaching,
54:16marking counseling and attrition
54:18available actually through our office
54:20and our outpatient office at Dana too.
54:22And I know that there's a whole set of at
54:24Bridgeport again and throughout actually
54:26the Yale system all the hospitals have
54:29in and outpatient wound ostomy support.
54:31So they do a lot of the teaching,
54:32and so there's support in the hospital
54:34before the hospital after the hospital.
54:36And if we have a stoma and
54:38a new stove on a patient,
54:39we send patients home with a visiting nurse.
54:41So from a physical support side,
54:44we have nursing staff and education
54:46pre and post operatively in place.
54:49But the real question is who
54:50needs a stone or who gets a stoma?
54:53And maybe more importantly,
54:55is that stoma going to be permanent?
54:59In this day and age, really,
55:00there's very few cancers that
55:02we make a permanent stoma form.
55:05Those are sometimes rectal cancers
55:06that are so low that they're invading
55:08the sphincter complex,
55:11and so,
55:11in which case we can't actually spare
55:13it in the stoma that we would create
55:15would be would actually be permanent.
55:17That's one of the few situations
55:18where I can tell you up front.
55:19We do use a permanent stoma.
55:21Most of the other surgeries we do
55:24sometimes will require a temporary stoma,
55:26and that's oftentimes in rectal
55:28cancer surgery.
55:29When we're operating what we call a low
55:32anterior resection or lower in the pelvis,
55:34and in that case if someone has received
55:36upfront chemotherapy and radiation,
55:38the risk of that basically for lack
55:39of a better word, the plumbing.
55:41We put the two ends together.
55:42The risk of that not healing perfectly
55:44in the face of radiation and chemotherapy
55:46before surgery is is a little higher there,
55:49and so oftentimes we do give patients
55:51a temporary stoma.
55:52And and in my practice,
55:53temporary means four to six weeks,
55:55usually three to four weeks after surgery.
55:57We do a radiology study to make
55:59sure that the.
55:59That hookup is watertight,
56:00at which point in time we close the stoma.
56:03Shortly thereafter,
56:04sometimes an emergency surgeries or in
56:06very frail patients who are having,
56:09you know,
56:09have come in with an emergency
56:11perforation from their cancer.
56:12Those are cases where we might
56:14sometimes have to also give a stoma,
56:16even though it's not a rectal cancer,
56:18but those usually with time and
56:20recovery and treatment can can recover,
56:22and we can usually close those domains
56:25down the line at the appropriate time.
56:27Amit
56:30well I think he I don't know how
56:31much I can add to to that, you know,
56:34I think Doctor Martin did a great
56:35job of of talking about that.
56:36I guess the only thing I would
56:38say in support of of doctor
56:40Manju's comments is that you know,
56:42I think the way we view taking care
56:45of our colorectal cancer patients
56:47is a journey and a relationship,
56:49not a transaction.
56:50And I think that's critical so that
56:53we've built into the process of
56:55how we take care of our patients.
56:58That ostomy support is baked in.
57:01So for example, in a practical way,
57:03what does that mean?
57:04Well, if the patient comes to us
57:05with a very very low rectal cancer,
57:07which means the rectal cancer is
57:09invading the muscles right at the
57:11bottom right near the anal canal,
57:13and we know we have to make
57:15an ostomy for that patient.
57:17We're going to do a lot of things for
57:19that patient that are not just involved
57:21with doing the surgery to remove it,
57:23but rather teaching that patient when
57:26they come in before they have the surgery,
57:28helping them work with.
57:31Other patients and connecting
57:33them to other patients who've gone
57:35through similar situations to
57:36counsel them on how they're going
57:38to adjust and then support them
57:40post operatively with hooking them
57:42into various ostomy support teams.
57:44And we have some of the
57:47best ostomy nurses you know.
57:48I don't know if there's an
57:50ostomy competition for ostomy,
57:51pre-op, education,
57:51and nursing,
57:52but I know we'd win or we would be
57:54super competitive 'cause we have
57:55just an incredible team and we're
57:57very lucky lucky that our patients
57:58have access to them and then also.
58:00Every patient that comes to
58:02us post-op really,
58:03whether they have a temporary
58:04ostomy or a permanent one,
58:06they're gonna get refitted.
58:07So as my body no longer
58:10fits into my wedding suit,
58:12you know folks who have their ostomies,
58:15their ostomy changes overtime,
58:16and so we have to provide that
58:19support for our patients lifelong.
58:23Thank you alright. Let's in that vein,
58:27I think this is a good time to bring
58:30in a discussion about radiation and
58:33so Doctor Kevin do is hear from
58:36radiation oncology. Thank you.
58:40Yes. Myself hello.
58:44Great can folks give me a thumbs up.
58:47They can see my screen perfect so
58:50I think this is actually a really
58:52nice place to talk about radiation
58:54as a lot of times when we talk
58:57about radiation for colorectal
58:59cancers we are talking about.
59:02Working together as a team,
59:03and especially with the surgeons and
59:06trying to enhance the surgical outcomes.
59:08So the thing that I really enjoy
59:11about really about GI oncology is that
59:14we are an inherently collaborative
59:16effort and I think the what folks
59:18have said about working as a
59:20team is one of my favorite parts
59:22about treating colorectal cancers
59:23and taking care of patients.
59:25Together with such a phenomenal team.
59:28The first thing I think to talk
59:30about is really the question of
59:32what is radiation oncology and
59:33I think intuitively you know,
59:35most everyone will know what
59:38gastroenterologists do, what surgeons do.
59:41Even medical oncology, I think,
59:44is pretty pretty much folks
59:46will know about chemotherapy,
59:48but radiation oncology,
59:50because you know,
59:51not many colorectal cancer patients will
59:55will actually encounter radiation treatments.
59:59Is a little bit of a question,
01:00:00and so I thought I would take a
01:00:03minute to talk about what is radiation
01:00:06oncology and then how do we use it in
01:00:09colorectal cancers to help patients.
01:00:11So let me see.
01:00:13OK,
01:00:13so in terms of the history
01:00:15of radiation oncology,
01:00:17it's it's worthwhile noting that
01:00:19we've actually been using radiation
01:00:22to treat cancers almost since
01:00:24the phenomena of radiation was
01:00:26first discovered in the 1800s.
01:00:28So this is a picture of the
01:00:31first X ray taken William Rankin,
01:00:34who discovered the mysterious X rays,
01:00:37actually took a picture of his wife's hand,
01:00:40and this is actually her wedding band there.
01:00:43Very famous historical picture.
01:00:45This really transformed and
01:00:47revolutionized cancer care.
01:00:48Before this there was no way to
01:00:50see inside a patient and detect
01:00:52cancers other than surgery other
01:00:54than opening up a patient.
01:00:56And so this really was an incredible
01:00:58step forward and almost immediately
01:01:00not only were we able to seek
01:01:03answers inside patients,
01:01:05but within a few months of the
01:01:06discovery of the phenomena of radiation,
01:01:09we were actually using radiation
01:01:10to treat cancer patients in the
01:01:12first cancer patient was treated.
01:01:14In 1896, in Chicago with who had a recurrent,
01:01:18inoperable breast cancer?
01:01:22The really the Golden Age of of
01:01:24Radiation Oncology came about in
01:01:26the 1950s at Stanford with Henry
01:01:29Kaplan and Saul Rosenberg.
01:01:30Using here,
01:01:31Henry Kaplan was one of our first
01:01:34machines that we use to deliver radiation,
01:01:37and Saul Rosenberg,
01:01:38really a chemotherapy giant and
01:01:41using combination chemotherapy and
01:01:43radiation to provide the first
01:01:46non-surgical cures of of cancer.
01:01:48And this is really a phenomenal
01:01:51step forward and really led to.
01:01:53Over the next few decades from
01:01:56the 50s till now,
01:01:57an explosion of cancer treatment
01:02:00options and really innovations
01:02:02in in curing patients.
01:02:05So right now,
01:02:07modern radiation therapy moving
01:02:10into 2022 is really based on
01:02:13all the advances in physics
01:02:15that have happened over the past few decades.
01:02:18All the huge advances in biology.
01:02:21And understanding how radiation
01:02:24interacts with with with cancer and
01:02:27then a really as I think Doctor Manju
01:02:30is saying something about iPhones.
01:02:33You know, advances in technology
01:02:36over the past few decades.
01:02:38Also all such that you know this is
01:02:40one of our modern radiation machines.
01:02:42You know, which has a lot of bells
01:02:45and whistles which we can use
01:02:47to really personalize a patient
01:02:49care and cancer treatments.
01:02:51In a very patient centric way,
01:02:54even though we are talking about you
01:02:56know this black box of radiation.
01:02:59So for colorectal cancers I couldn't
01:03:01have had a better introduction into why
01:03:04we use radiation for colorectal cancers
01:03:06than from Doctor Kane and Doctor Manju,
01:03:08who have a keen appreciation of the role
01:03:11of radiation for colorectal cancers.
01:03:14But the the reason why we use radiation
01:03:16in colorectal cancers is that for most
01:03:19colon cancers we do not need to use
01:03:21radiation and and that's a good thing.
01:03:23But as we get further down to the
01:03:26end of the colon, we enter this.
01:03:29Part of the of the bowel called
01:03:31the ****** and that ****** as
01:03:33has already been discussed,
01:03:35is right here at the bottom
01:03:37of the pelvic bowl.
01:03:38And as you get farther down
01:03:40deeper into the pelvis there the
01:03:43the space here gets narrower.
01:03:45There's all these muscles here that control
01:03:47things like continents and you know,
01:03:49I think the idea of a colostomy
01:03:51has already been brought up.
01:03:52If you cut too close to these muscles or
01:03:55the tumors invading into those muscles
01:03:57and and that's really where a radiation.
01:04:00Can help because.
01:04:02That we can give radiation before surgery
01:04:06in order to reduce the tumor size.
01:04:09To get the tumor to pull away
01:04:11from these muscles,
01:04:12pull away from the pelvic sidewall.
01:04:14And by doing this we can improve
01:04:17surgical outcomes and decrease the
01:04:19risk that the cancer comes back
01:04:21even after a successful surgery.
01:04:24In addition,
01:04:24we can even get the cancer to
01:04:28shrink away from these muscles
01:04:30that control continents and.
01:04:33Allow surgeons to to to potentially
01:04:37preserve more of those muscles and
01:04:40decrease the risk of having patients have
01:04:43a permanent colostomy after surgery so.
01:04:48In addition,
01:04:49as I think was mentioned as well
01:04:52in in Doctor Shahar's case,
01:04:54you know for patients who may not
01:04:56be in the best health you know who
01:04:59may not be candidates for these
01:05:01big surgeries that we may actually
01:05:03use chemotherapy and radiation
01:05:05instead of surgery for patients
01:05:08who may not be medically medically
01:05:11able to to handle surgery.
01:05:15So,
01:05:16as I alluded to all these advances
01:05:18in technology and and in in how we
01:05:22think about using radiation for cancer
01:05:26treatments really is an early example.
01:05:28As I said,
01:05:29going back 100 years of of how we
01:05:32personalize care for patients,
01:05:34and you know,
01:05:35nowadays we talk about a
01:05:36lot about personalized care,
01:05:38but in radiation we've been
01:05:40personalizing care for many,
01:05:42many years. Now. One of the main ways.
01:05:45The way that we do is in a measured way
01:05:47that we decide what to treat with radiation.
01:05:50What we decide, how we aim, the radiation,
01:05:53and everybody is different and
01:05:55everybody's body is different and we
01:05:58can actually consciously these days
01:06:00with all the technology, figure out
01:06:02precisely how to aim the radiation.
01:06:04This is an example of a radiation
01:06:07plan where we're looking at a CT
01:06:09scan through a patient body and
01:06:11here you can see the leg bones here
01:06:13attached to the hips, hip bones.
01:06:15This is the front of the patient
01:06:17is back with the patient and back.
01:06:19Here is the ****** the red and the blue
01:06:22are the radiation doses that we're
01:06:25targeting to the ****** as well as to
01:06:28the lymph nodes around the ******.
01:06:30This is a side view where this is the spine.
01:06:33The curve of the back and the tailbone.
01:06:35And as we're looking to at the
01:06:38patient to side and the CT scan.
01:06:40And what you can see is we can
01:06:42actually aim radiation at the ******
01:06:43at the lymph nodes and actually
01:06:45spare this middle part where this is.
01:06:47Vowel,
01:06:47so we can actually spare non involved
01:06:49bowel and you can see that over here as well.
01:06:52In the front we can spare non involved
01:06:54battle from radiation exposure
01:06:55treating only what we need to do,
01:06:58reducing the side effects of diarrhea and
01:07:02and and things like that from radiation,
01:07:06exposure of the bowel.
01:07:09Another very simple trick that we can use
01:07:12during radiation treatment is positioning.
01:07:14So everybody again is different.
01:07:16Sometimes we can actually very simply
01:07:18just lay a patient down on their
01:07:21stomachs on the treatment table.
01:07:22You know patients head would go here,
01:07:24and there's an opening here where
01:07:28patients stomach fall through this
01:07:30hole and you can see that on this CT
01:07:33scan where again looking at the side
01:07:35of the patient with the ****** here.
01:07:38At the bell actually can fall out of the
01:07:41pelvis forward into this opening here
01:07:43and really spatially put quite a bit
01:07:46of distance between where we're aiming
01:07:48the ****** and then the small bowel,
01:07:51which causes a lot of the side
01:07:53effects of radiation.
01:07:54And so again in a way
01:07:57that we can use anatomy,
01:07:59positioning and technology to reduce
01:08:01the side effects of radiation
01:08:04and make radiation safer while
01:08:06maintaining the effectiveness.
01:08:10And then the final
01:08:12way that I'd like to talk about in terms
01:08:14of using radiation is really for folks,
01:08:17regardless of if they have
01:08:19colon cancers or rectal cancers.
01:08:21If if the cancer is spread to other
01:08:23parts of the body and you know I think
01:08:27this is something where there's so many
01:08:31treatment options for colorectal cancers
01:08:33these days across all stages of cancer,
01:08:37that even if. Cancers have spread
01:08:39to other parts of the body.
01:08:41I I do think there's still a really
01:08:44good measure of hope, and many,
01:08:45many treatment options for them.
01:08:47And Doctor Kaminski will talk
01:08:49more about that, but these days,
01:08:52people are living longer
01:08:53and longer with cancer.
01:08:55We're curing more patients with cancer,
01:08:57but for patients who have have have cancer
01:09:01that spread to other parts of the body,
01:09:03we can. We can actually think
01:09:05that they can live for for many,
01:09:06many years at this point and.
01:09:09Uh, one of the tools in our in our
01:09:13toolbox that we have to to treat
01:09:16metastatic deposits is radiation.
01:09:17Using radiation here again in the
01:09:20color colored lines to treat spots
01:09:23of cancer that have spread to liver
01:09:25or spots that have spread to lungs
01:09:28in order to in a noninvasive way,
01:09:31a BLT these tumors and improve
01:09:35Disease Control in these patients so.
01:09:39These are just some examples,
01:09:42again of how we use radiation
01:09:44therapy in a very tailored way and
01:09:47part of a lot of that is really in
01:09:49talking to the patients you know,
01:09:51trying to figure out what
01:09:52their priorities are,
01:09:53what their hopes are you know,
01:09:54and what what patients really
01:09:56want out of their treatment.
01:09:57And it is not a one size fit all
01:10:00treatment and as Doctor Khanna has really
01:10:04emphasized and described very well,
01:10:06it's a team approach and it's not just
01:10:08you know me as a radiation oncologist.
01:10:10Sitting there talking to you.
01:10:12It's all of us talking to you and
01:10:15sharing our thoughts and and and and
01:10:18trying to understand the patient.
01:10:20So, uh, so again, so I'll I'll.
01:10:25I'll finish up there and turn
01:10:28it back to Doctor Krzeminski.
01:10:31Thank you Kevin. That was a a great talk I I
01:10:35had a a question that we
01:10:37often get asked which is why?
01:10:38Why radiation takes so long to finish
01:10:41and whether there are any options to do
01:10:43it in the shorter way. I thought you
01:10:45said to keep this talk to a short.
01:10:49So, so I think a lot of it is is historical.
01:10:53In all honesty, so at the beginning
01:10:55you remember I I said in the 1800s
01:10:57when radiation was discovered.
01:10:59You can imagine that in and when you're
01:11:02talking about unregulated sort of
01:11:04regulation radiation when you don't really
01:11:06understand too much about radiation that
01:11:08the toxicities can actually be substantial,
01:11:11and so in order to make radiation
01:11:15more tolerable in the 50s,
01:11:17Forties, 50s, this movement.
01:11:19Happened in radiation which said that we can
01:11:22actually cure the same number of patients,
01:11:24but we it makes radiation safer
01:11:26and more tolerable if we give it
01:11:28in small doses over many weeks,
01:11:30and this so called fractionation
01:11:32of radiation was really one of
01:11:35the biggest advances in the last
01:11:37century as technology has improved,
01:11:39we can actually kind of it's kind
01:11:41of a back to the future sort of
01:11:43thing where we can now because of
01:11:45the way we deliver radiation better.
01:11:47We can actually go backwards.
01:11:49We can actually deliver a higher doses of.
01:11:51Radiation in shorter courses safely,
01:11:54so we're starting starting starting
01:11:56to gradually move back to shorter
01:11:59courses of radiation,
01:12:00but a lot of the history of radiation is
01:12:03is with extended courses of radiation,
01:12:06and you know,
01:12:07we're we're we're we're working on it,
01:12:09though.
01:12:10We're trying to make radiation
01:12:12more convenient and and and safer
01:12:14for our patients.
01:12:16Perfect thank you alright, and so let's
01:12:19we'll get to the medical oncology part.
01:12:22Doctor Justin Persico is with us to
01:12:27talk about advances in treatment. Thanks
01:12:31Jeremy, I'm gonna. Get my screen up here.
01:12:57OK coming up so I first want
01:12:59to thank all my colleagues.
01:13:04Father, so far I've really enjoyed it.
01:13:07I really like how I've driven home the
01:13:10idea of a team breached based approach
01:13:13to colorectal cancer care and my job
01:13:15as part of that team is as the medical
01:13:17doctor giving any of the medicines as
01:13:20well as doing a lot of the surveillance
01:13:22to follow up the monitoring for
01:13:24years to come after somebody has been
01:13:27diagnosed and treated with cancer.
01:13:29And also I'm going to hit on.
01:13:30I think some themes that my colleagues
01:13:32have been been hitting on here,
01:13:34which is that we are all engaged in
01:13:38effort to reduce the overall toxicity.
01:13:41Side effects improve recovery
01:13:43times from surgery,
01:13:44like invert about and and a significant
01:13:46part of what I'm going to talk about
01:13:48today is how we can improve on the
01:13:50treatments that we give as medical
01:13:52oncologists chiefly chemotherapy treatment.
01:13:54So I'm going to pick up from where
01:13:57the surgeons left off and talk about.
01:13:59Well, what happens next after
01:14:01the surgery when you,
01:14:02when you first meet the medical oncologist,
01:14:04what do you?
01:14:04What are you there to talk about?
01:14:05What are you likely to hear?
01:14:08And I'm going to try to focus on some
01:14:10of the key points of the presentation
01:14:12and the interest interest of time.
01:14:13I'm not going to go over some of the
01:14:15anatomy as you see in the picture here,
01:14:17But I'll just mention,
01:14:18you know,
01:14:18with a little bit about the background
01:14:21of of colorectal cancer and
01:14:22the burden of slides.
01:14:26Like it's something were you able
01:14:28to see them initially or yeah?
01:14:34Yeah, looks like it stopped
01:14:36sharing for some reason.
01:14:37Try this again.
01:14:46Alright, are you able to see it?
01:14:48Yeah perfect OK great.
01:14:51So there is approximately 150 new diagnosis
01:14:54of colorectal cancer each year in the US,
01:14:56of which about 70% of them are
01:14:59involving the colon and 30% involving
01:15:01the ****** and I have the picture here
01:15:03just to remind everybody about the
01:15:05different parts there of the colon.
01:15:07My focus for today is really going
01:15:08to be talking about colon cancer,
01:15:10and in particular stage two and stage three,
01:15:13which I'll define for you shortly.
01:15:15Rectal cancer is another topic
01:15:16after do alluded to some of the
01:15:18specifics that we that we think
01:15:20about when it comes to treating.
01:15:22Rectal cancer,
01:15:23but I'm gonna leave that out for
01:15:25today and I will point everybody
01:15:27then in case they do want to learn a
01:15:29little bit more about that that this
01:15:32presentation from this month last year,
01:15:34there was an excellent presentation
01:15:36by Doctor Cort Manske higher so
01:15:38we can always find that on the
01:15:39website or it's on YouTube as well.
01:15:46OK, now my slide is not advancing.
01:15:48Sorry about the technical difficulties.
01:15:56OK, so and this just
01:15:58briefly mention this slide,
01:16:00which is just showing the improvements
01:16:01that we made in treatment of
01:16:03colorectal cancer over the decades,
01:16:04and that the mortality has
01:16:07been decreasing significantly,
01:16:08both because of better treatments.
01:16:10But I think primarily because of
01:16:12better screening and the top couple
01:16:14top top two lines here you'll see
01:16:16the incidence or the number of cases
01:16:18of colorectal cancer that we see and
01:16:20how that's declined significantly,
01:16:22primarily now because of screening
01:16:24techniques like colonoscopy.
01:16:25Where these precancerous lesions
01:16:27can be identified before they
01:16:29actually become cancer.
01:16:30So another plug for for screening here.
01:16:34And one of the first things you'll
01:16:36talk about with the medical oncologist
01:16:38is the stage of the cancer.
01:16:40'cause it's really determines for us
01:16:42how we should approach the next steps
01:16:44after surgery and the way we stage
01:16:46cancer is using what's called the TNM system,
01:16:48or tumor.
01:16:50Nodal metastasis system.
01:16:52And I have a a picture of sort
01:16:54of explaining how we separate
01:16:56the different T stages or tumor
01:16:59stages showing a picture of the
01:17:01of the colon with the bowel part
01:17:03that's labeled as bowel being.
01:17:04The inner part of the colon and then
01:17:06the layers of the colon heading towards
01:17:08the outer part of of that issue,
01:17:10and small tumors involving just
01:17:12the layer first layer of the of the
01:17:15colon are staged as T1 and as you
01:17:17invade deeper in through more layers,
01:17:19you increase the stage,
01:17:21leading all the way to what we
01:17:23call it T4 tumor,
01:17:24which actually invades through
01:17:25the outer layer of the colon.
01:17:27The Internodal stage is determined
01:17:29by the number of lymph nodes that
01:17:32are involved with the cancer.
01:17:34So when you have your surgery,
01:17:36the surgeon, as as explained by the surgeons,
01:17:39it removes the section of colon
01:17:40that's involved with the cancer and
01:17:42along with that the blood vessels
01:17:43and the lymph nodes that are all
01:17:45associated with that section and
01:17:47all of that is taken to the lab and
01:17:49analyze under the microscope and
01:17:50if any lymph nodes are involved,
01:17:52those are counted as part of the
01:17:55part of the pathology.
01:17:57The MCS refer referring to metastases
01:17:59basically means if we see cancer
01:18:01in any other parts of the body.
01:18:03For example,
01:18:03the liver or the lung as Doctor do head show.
01:18:06This is typically known,
01:18:07and in this situation,
01:18:09before having surgery would
01:18:11typically have some forms of imaging,
01:18:13cat scan or MRI that would be
01:18:15there to look for any evidence of
01:18:17the cancer having already spread,
01:18:18because that might change the
01:18:20overall treatment strategy approach.
01:18:24We use that information to group the.
01:18:28Patients into different stages.
01:18:30And here I have outlined
01:18:32that stage one tumor is,
01:18:34in general our tumors that are not
01:18:36eating very deeply and have no lymph
01:18:38nodes involved in the approach of those
01:18:40cancers is typically just observation.
01:18:42We have thankfully a low risk of recurrence.
01:18:45There have a high rate of being
01:18:47cured with surgery alone,
01:18:48so so we just monitor those patients.
01:18:51Stage two tumors invade more
01:18:53deeply into the into the colon,
01:18:55but still have no lymph nodes.
01:18:56And this is where there's a little bit.
01:18:59Or difficulty in in determining the
01:19:01optimal strategy because we understand
01:19:03that there is a higher risk of recurrence
01:19:05and a lot of the efforts are trying
01:19:08to that that we're doing right now.
01:19:10We're trying to identify who are
01:19:12those patients with in stage two
01:19:13that are at the highest risk and
01:19:15potentially offer them treatment
01:19:17to try to reduce that risk.
01:19:18Stage three cancer is now involved
01:19:22lymph notes and that is concerning
01:19:25because that is the first time or
01:19:27first behavior of a cancer starting
01:19:30to spread throughout the body and
01:19:32the hope is that we can stop it at
01:19:34that point before it does spread
01:19:36to distant sites within the body.
01:19:38And in this case there is a much
01:19:40higher risk and therefore additional
01:19:42treatment after surgery is recommended.
01:19:45Stage four cancer means that the cancer
01:19:47has already involved other organs,
01:19:49and that's another topic that
01:19:51could be talked about on its own.
01:19:53So we're going to skip over that for today.
01:19:59So why would we consider more treatment,
01:20:02specifically, chemotherapy?
01:20:02Well, this graph shows some of
01:20:04the risks that are associated with
01:20:06the diagnosis of colon cancer.
01:20:08As I mentioned stage one cancers,
01:20:10I think we have a low risk.
01:20:11The orange bar indicating what is what
01:20:13is the risk of this cancer coming back
01:20:15within the next five years or so,
01:20:18and because the risk is low,
01:20:20there's not really much we
01:20:22can do to improve on that,
01:20:24and so observation is just recommended.
01:20:26But as you go up in stage
01:20:28from stage two to stage 3.
01:20:29That risk significantly climbs which
01:20:31it with the average patient having
01:20:33a stage three cancer having about a
01:20:3550% chance of their cancer recurring,
01:20:37so we'd like to do something if we can
01:20:38to reduce that chance and increase
01:20:40those patients chances of being cured.
01:20:45So when it comes to this stage two tumors,
01:20:47it's a bit more questionable how
01:20:49how we decide who is at the higher
01:20:51risk within that group and who might
01:20:53benefit from additional treatment the
01:20:56traditional way we look at this is by
01:20:58actually looking at the features of
01:21:00the cancer when those samples that
01:21:02are removed from from the surgery
01:21:04are analyzed in the lab and there
01:21:06are certain high risk features that
01:21:07might make us think that somebody is
01:21:09at a high enough risk that they would
01:21:11benefit from additional treatment.
01:21:13There are now also more sophisticated
01:21:15ways to help us determine this risk.
01:21:18Some of the first ideas that were
01:21:20developed were to look at the genome
01:21:23within the cancer and specifically
01:21:25at genes that are known to predict a
01:21:28higher risk of the cancer having bad
01:21:31behavior and potentially coming back.
01:21:33I've listed some of the available tests here,
01:21:35and so sometimes this test might be
01:21:38ordered by her oncologist to help
01:21:40him or her with a decision about.
01:21:43Other offer chemotherapy.
01:21:46The sort of new frontier that there's
01:21:48a lot of interest in is looking at
01:21:50whether or not we can detect the
01:21:52presence of tumor DNA in your blood.
01:21:54People who have a tumor DNA detected
01:21:57in their blood are felt to be at a
01:21:59higher risk for their cancer recurring,
01:22:01and maybe the patients who are best
01:22:04served by getting adamant chemotherapy
01:22:07if they have stage two disease and
01:22:09we'll talk about it a little bit
01:22:11later on about clinical trials that
01:22:12are looking at this,
01:22:13this is not yet the standard of care,
01:22:15but appears to be.
01:22:16On the cusp of becoming the standard of care.
01:22:19And I'm not going to go into this
01:22:21in the sake of time,
01:22:22but I I had a link down here.
01:22:23I was thinking of showing everybody,
01:22:25but basically there are also these
01:22:27normal grams or calculators that that
01:22:29we can use as medical oncologists where
01:22:30we can input information about the
01:22:32the patient and the patient's cancer
01:22:34to come up with a risk score to help
01:22:37us guide our treatment decisions.
01:22:39So there's actually something that's
01:22:40available for patients to access as
01:22:42well so they can also go along through
01:22:43this with their with their own colleges.
01:22:45And I've done this with many patients in
01:22:47the past to help us with our decisions.
01:22:52So when somebody does need chemotherapy,
01:22:54what are the drugs that we use?
01:22:55Well, the mainstay in the backbone
01:22:57of treatment are our class of drugs,
01:22:59which we call floral, permittees and it
01:23:02comes in both intravenous and oral forms.
01:23:05In the US, we primarily use these two forms,
01:23:07the intravenous being called 5 fluorouracil
01:23:10or five FU in the oral form being called
01:23:13keep side mean or the brand name is valoda.
01:23:16Commonly the intravenous form of
01:23:17these drugs is combined with something
01:23:19called local board.
01:23:20Which is not a chemotherapy drug,
01:23:22but actually an adjunct.
01:23:23It's actually a form of folic acid that helps
01:23:26the drug better target its target enzyme,
01:23:30which is what actually
01:23:31kills the cancer cells,
01:23:32so it improves the efficacy with
01:23:34adding little to no increase toxicity.
01:23:37The other drug that is commonly used is
01:23:40something called oxaliplatin or locks.
01:23:43It in is the brand,
01:23:44and this is a drug that can add a little bit
01:23:47more to the backbone of the floor perimeter.
01:23:50And for patients who are at the highest risk,
01:23:52the combination has been shown to to
01:23:55be better in terms of helping them
01:23:57have a higher chance of being cured,
01:24:00and when we combine these drugs we
01:24:02use the following acronyms that you
01:24:04may hear when you talk with your
01:24:05medical oncologist.
01:24:06When you combine the.
01:24:07Drive if you in the oxalic plan,
01:24:09we call that regimen folfox,
01:24:11and when you combine the Cape
01:24:12side to being in the oxaliplatin,
01:24:13we call that regimen key box.
01:24:15Or are you sometimes might hear AZ
01:24:16locks if they use the brand name Xeloda?
01:24:22So what are the benefits of
01:24:24chemotherapy and what are the potential
01:24:26downsides or adverse effects?
01:24:27Well, the benefit as has been
01:24:30shown in multiple clinical trials,
01:24:32is that it reduces the risk of cancer
01:24:34coming back by about 30 to 35%.
01:24:36So that's increasing your chance
01:24:38of being cured of the cancer.
01:24:40Unfortunately,
01:24:40chemotherapy does is associated
01:24:42with some significant side effects,
01:24:45and I have this list I've listed here.
01:24:46I was by no means inclusive,
01:24:48but some of the more common
01:24:51effects that we see.
01:24:52I'll highlight a couple in particular,
01:24:54I would say fatigue is by far the
01:24:57most common effective chemotherapy
01:24:59and the peripheral neuropathy,
01:25:00which is in effect on the nerves
01:25:03that are in the periphery of our
01:25:06bodies and our fingers and toes
01:25:08can can be very problematic,
01:25:10and one of the.
01:25:12Potential side effects that we can
01:25:15that that may result in a treatment
01:25:17changes or or limit the amount of treatment.
01:25:20Most of these are monitored or all
01:25:23of these I should say are monitored
01:25:25very closely and can be managed.
01:25:27There are rare more severe
01:25:29side effects listed here,
01:25:31but we also monitor very closely
01:25:32for those who make treatment
01:25:33as safely as safe as possible.
01:25:38However, we're always looking to see how
01:25:40can we improve the toxicity of treatment,
01:25:42and I would say the number one thing that
01:25:44we do is by maximizing our supportive care.
01:25:46So these are medicines that we might
01:25:48give you or use to help prevent or reduce
01:25:50the side effects as well as support
01:25:52services that we have to help as well.
01:25:55For example, if somebody really is
01:25:57struggling with appetite during treatment,
01:25:59then we have dietitians that work with
01:26:00us that can become involved and to
01:26:02help make sure the patient is getting
01:26:05the appropriate nutritional support.
01:26:07Through their through their treatment,
01:26:09there's also always dose adjustments
01:26:11that can be made.
01:26:12Chemotherapy is typically tailored
01:26:15individually to the patient.
01:26:16We use variables such as the patient
01:26:18height and weight and laboratory
01:26:20results to adjust your dose even
01:26:22sometimes treatment the treatment,
01:26:24but sometimes we don't get it exactly right
01:26:26and we have to make an adjustment there.
01:26:28A lowering the dose or or altering
01:26:30the schedule of the treatment.
01:26:32The other goal is to use the
01:26:34minimum treatment necessary.
01:26:35Now that should be self explanatory,
01:26:39but a lot of like what Doctor do had
01:26:43just mentioned a lot of the treatments,
01:26:45doses and amount of treatment we give
01:26:48are somewhat historical and with more
01:26:50study overtime we found that maybe maybe
01:26:52we can adjust or reduce the amount of
01:26:54treatment and still get the same effects.
01:26:59So when we look at whether or
01:27:00not we can reduce chemotherapy,
01:27:02there are some studies that can
01:27:04help inform us on this decision.
01:27:06So initially some big clinical trials
01:27:08set the standard that we would give six
01:27:10months of chemotherapy for patients who
01:27:12are at the highest risk of recurrence.
01:27:15And this is what had been
01:27:17done for for many years.
01:27:19However, analysis of more and more data
01:27:22coming from multiple trials looking
01:27:25at the treatment of colon cancer has
01:27:28called some of this into question,
01:27:30and in particular,
01:27:32this idea group collaboration looked
01:27:34at this fairly recently and challenged
01:27:36whether six months should be the
01:27:38standard of care for all patients.
01:27:40What they did is they looked at a
01:27:42patient in stratified them into low
01:27:43and high risk groups to see if there
01:27:46was a difference in whether outcomes
01:27:47were just as good with less treatment,
01:27:49as with more treatment.
01:27:50They also looked at the impact of
01:27:52the intensity of the treatment.
01:27:54How many doses were given for example,
01:27:56and also looked at whether their
01:27:58differences based on the age of the patient,
01:28:00particular or their patients over
01:28:02the age of 7.
01:28:06In these studies, they died.
01:28:09They sorry, defined low risk patients
01:28:11as those who have three or fewer lymph
01:28:13nodes involved with their cancer.
01:28:15No evidence that their cancer had
01:28:17perforated the colon or caused an
01:28:19obstruction and no advanced tumors.
01:28:20In meeting through that
01:28:22outer layer of the colon.
01:28:23As I mentioned before and in those patients,
01:28:26they found that three months of the
01:28:28regimen with capecitabine and oxaliplatin
01:28:30had the same efficacy as six months,
01:28:32making three months.
01:28:33The new standard of care for those.
01:28:36Patients this, interestingly,
01:28:37was not true for regimen
01:28:39that used for uracil,
01:28:41with the oxaliplatin,
01:28:42it's not entirely clear why there
01:28:44was a small difference there,
01:28:46but for now the keep side,
01:28:48I mean based regimen,
01:28:49is that regiment of choice for people who
01:28:52are eligible for a three month treatment
01:28:55rather than a six month treatment.
01:28:57Now, in patients who are older over 70,
01:28:59there's been some study on this
01:29:01already before and in this database.
01:29:03It was also not entirely clear
01:29:05that there was any any difference
01:29:08between younger and older patients.
01:29:11However,
01:29:11the trends overall,
01:29:12or that the likely benefit to
01:29:15combination chemotherapy may be small,
01:29:17and that the risk of toxicity is
01:29:20is increased in older patients.
01:29:22So this is something that really needs
01:29:23to be an individualized discussion
01:29:25between the oncologists and the patient.
01:29:27And takes into account multiple factors,
01:29:29specifically the patients performance.
01:29:31That is how functional they are,
01:29:33what other medical comorbidities or or
01:29:36other medical diseases that they have.
01:29:38The other thing they looked at here is the,
01:29:41specifically the drug oxaliplatin,
01:29:43and when they looked at patients
01:29:46who were planning to receive six
01:29:48months of chemotherapy but had to
01:29:51have their doses of their axali,
01:29:54Platten stops or reduced because
01:29:56of toxicity if they if they
01:29:58received at least 50% of the doses,
01:30:01they had the same outcomes as those who
01:30:03received all the doses over six months.
01:30:06So this lead.
01:30:07To the thought that perhaps
01:30:09in this drug at least,
01:30:11the oxaliplatin could be reduced
01:30:12as part of this treatment.
01:30:16And why does this matter?
01:30:18Well, in particular,
01:30:19reducing the oxaliplatin has been shown
01:30:21to cut the overall risk of significant
01:30:23adverse effects by 1/3 to 1/2,
01:30:24so it would be very helpful
01:30:26if we could reduce it.
01:30:28Solid plan is the drug that causes
01:30:31that peripheral neuropathy symptom
01:30:32I mentioned and it can lead to
01:30:35permanent neurologic effects.
01:30:36Including this,
01:30:38including functional issues related to this.
01:30:42The risk of to show you the difference,
01:30:45the risk of peripheral neuropathy
01:30:47with only three months of
01:30:48the drug was only about 10%,
01:30:50whereas if you were to get a full six months,
01:30:52that risk goes up to 30%.
01:30:54Now this is the best data we've had
01:30:56so far and it's certainly provocative,
01:30:58and I think becoming incorporated
01:30:59more and more into practice.
01:31:01But there may be individual reasons
01:31:03for each patient that they should
01:31:05discuss with their oncologists why
01:31:07treatment may not be recommended to
01:31:09be reduced in their particular case.
01:31:14So in summary, patients with low risk
01:31:16colon cancers can be treated with three
01:31:19months of chemotherapy instead of 6.
01:31:21Patients who are older should
01:31:23discuss with their oncologists and
01:31:25be counseled about the risk versus
01:31:27benefit of the using combination
01:31:28chemotherapy rather than just using
01:31:30one of the floor remedy drugs alone.
01:31:34Patients who experience neuropathy
01:31:35during their treatment may not derive
01:31:37much benefit from more than three
01:31:39months of the oxaliplatin drug,
01:31:41and so it appears that it is safe
01:31:43and does not affect outcomes if we
01:31:45have to stop that drug early due to
01:31:48the risk of worsening neurotoxicity.
01:31:51And patients who tolerate the oxaliplatin,
01:31:53perhaps should continue until we
01:31:55have more information and more data
01:31:57on this on an individualized basis,
01:32:00the risk really should be discussed
01:32:03between you and your oncologists and
01:32:05individualize to your particular case.
01:32:10So I wanted to just take a minute to talk
01:32:12about some future directions and give a
01:32:14plug for our clinical research efforts,
01:32:16which at El we have a very robust
01:32:18clinical trial portfolio and
01:32:20always trying to advance the field.
01:32:22The first two studies on to talk about
01:32:25here are ones that are available here
01:32:27at Yale for our patients and one of
01:32:30the ways we're looking to improve the
01:32:31chances of being of a patients being
01:32:33cured of their colorectal cancer is by
01:32:35adding immunotherapy to their treatments.
01:32:37This is a very hot topic.
01:32:39And as a real breakthrough in the
01:32:41treatment of cancer in general,
01:32:42and in particular in colon cancer,
01:32:44it appears to be highly effective
01:32:45for patients that have what is
01:32:47called Linda Syndrome,
01:32:48which is a deficiency in DNA repair.
01:32:50So we have ongoing trials looking at
01:32:52adding these drugs to see if we can
01:32:55increase their chances of being cured.
01:32:57We also have for us looking at the
01:32:58use of the circulating tumor DNA
01:33:00testing that I mentioned before using
01:33:02that to help stratify the risk for
01:33:04patients who have stage 2 colon cancer.
01:33:07Where, as I mentioned,
01:33:08there's a bit more ambiguity about.
01:33:09Who may benefit and who may not
01:33:12benefit from chemotherapy?
01:33:13In other centers they are looking
01:33:14at things like adding a third drug
01:33:16to the chemotherapy regimen,
01:33:18so this is in particular may be
01:33:20helpful for higher risk patients.
01:33:22And there's also trials looking at
01:33:24adamant cancer vaccine therapy.
01:33:25Another form of immunotherapy.
01:33:27Again,
01:33:28trying to reduce recurrences and
01:33:31improve chances of being cured.
01:33:33So I think I'll finish there and I
01:33:35thank you all for your attention and
01:33:37I'll be happy to answer questions
01:33:39and look forward to the discussion.
01:33:44Alright. Thank you Justin
01:33:47that was that was great.
01:33:50I think we've we've gone a long time
01:33:53tonight I I think it's clear that all
01:33:56of our panelists are very enthusiastic
01:33:59about what they do and how we can.
01:34:02We can help patients with colorectal cancers.
01:34:06I don't, I don't see any.
01:34:10Any questions in the the
01:34:12Q&amp;A or the OR the chat,
01:34:13and so I think I'll take this opportunity
01:34:17to to say that there is a lot that we can
01:34:22do to to treat cancer and cure cancer,
01:34:26but still the best thing we can do is
01:34:28prevent it from happening in the 1st place.
01:34:30And so I would say that that not only
01:34:34includes all of the various ways that
01:34:37we can screen for colon cancer with.
01:34:40As Doctor Satcher outlined
01:34:42at the very beginning,
01:34:44but also by taking good care of
01:34:47ourselves and focusing on a healthy
01:34:50lifestyle that includes exercise,
01:34:52a diet that is full of fruits and vegetables,
01:34:56reducing alcohol intake
01:34:58and and reducing stress.
01:35:01And those are practical
01:35:02things that that all of us,
01:35:04even those of us on the panel that probably
01:35:08can do a better job of everyday so.
01:35:10I'd like to thank all of our
01:35:13panelists for joining us tonight.
01:35:15I'd like to thank Cindy Barassi from
01:35:17the Colon Cancer Foundation for Co.
01:35:20Sponsoring this,
01:35:21and I'd like to thank everybody
01:35:23who took time out of their evening
01:35:26tonight to to join us and learn a
01:35:28little bit more about this disease
01:35:30and hopefully spread the word.
01:35:32So thank you and have a great night.
01:35:37Thanks everyone.