Robotic Surgery for Colon and Rectal Cancers

December 07, 2020

Information

December 6, 2020

Yale Cancer Center

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00:17Welcome to Yale Cancer Answers with
00:19your host, Doctor Anees Chagpar.
00:21Yale Cancer Answers features the
00:23latest information on cancer care
00:25by welcoming oncologists and
00:26specialists who are on the
00:28forefront of the battle to fight
00:30cancer. This week it's a
00:31conversation about the use of
00:33robotic surgery for colon and
00:35rectal cancers with Doctor George
00:37Yavorek. Doctor Yavorek is a
00:39clinical instructor of surgery
00:40specializing in gastro bariatrics
00:42at the Yale School of Medicine
00:44where Doctor Chagpar is a
00:46professor of surgical oncology.
00:48George, maybe we can
00:50start off by talking
00:53about screening for colon cancer.
00:55I understand that guidelines
00:57have recently changed in
00:58that regard.
01:00Yes, we've seen over the last 10 years
01:02that the incidence of colon
01:04cancer in younger individuals has
01:06increased by about 2% per year
01:08over the last five years or so,
01:11so the recommendations have
01:13changed to start screening
01:14at age 45 rather than age 50.
01:17Tell us a little bit more about
01:19what that screening entails because
01:22there seems to be a potpourri of
01:25different screening options for people,
01:27and they may be wondering about what
01:30screening technique is best for them.
01:33There are several options and most people
01:35would agree that colonoscopy is the
01:38best screening tool because it can
01:39also be therapeutic at the time.
01:42If you do find a polyp or a larger lesion, it
01:46can be removed or biopsied at the same time.
01:50Other options would include
01:51fecal occult blood testing.
01:53Which is not as specific.
01:56There is now DNA testing, Cologuard,
01:59which is rather specific for advanced
02:01lesions, tumors or large polyps,
02:04but when you get to smaller polyps,
02:07the sensitivity is not very good, it is
02:12good for people who don't want
02:14to go through a colonoscopy,
02:16or perhaps because of medical reasons
02:18can't do that.
02:19Other options might include
02:20what they call ECT collography,
02:22which is essentially a virtual colonoscopy.
02:24The sensitivity is roughly
02:26equivalent to a colonoscopy.
02:27However,
02:28if something is found then you
02:30have to go through a colonoscopy
02:32to have it removed or biopsied.
02:36And so it sounds like there's
02:38so many factors that are involved
02:40for people to try to parse out.
02:43What's the best technique for them?
02:45That's probably a discussion that
02:47they have with their family doctor.
02:49or gastroenterologist
02:52or colorectal surgeon.
02:54Someone who does screening and
02:56can tailor the screening
02:59program to the individual.
03:03And so now that the screening
03:05guidelines have changed and they've
03:07recommended starting screening at 45,
03:10is that for average risk people or is
03:13that for people who may have other
03:16predisposing factors?
03:17No, that's for average risk.
03:20People with a higher risk
03:22actually would start sooner.
03:24Typical recommendation for someone with
03:26a first degree relative who has had
03:30colon cancer is to start at least 10 years
03:33younger than when that cancer was diagnosed.
03:36So if the person has a parent who
03:39had colon cancer at about age 50,
03:43they should start at age 40.
03:45Other high risk situations might
03:47be someone with Crohn's disease
03:49or inflammatory bowel disease,
03:51or someone with a history of
03:53Polyposis syndrome that would
03:55increase their risk of developing
03:57polyps and possibly cancer.
04:00So when should those people be screened?
04:02I mean, presumably people with
04:04Crohn's disease or other forms of
04:07IBD or Polyposis syndrome likely
04:09would have already had a colonoscopy,
04:11but when would be the bare minimum
04:13time that they should actually start
04:16getting regular screening for cancer?
04:19Well, typically when they first are seen
04:21and diagnosed with the problem
04:24whatever their condition might be,
04:26they're likely going to have an
04:28initial colonoscopy to evaluate the
04:30situation and then future surveillance
04:32colonoscopies would be based on that.
04:34So typically if someone were
04:36diagnosed with Crohn's and is in their 20s,
04:38it's likely they would have a colonoscopy
04:41at that time and then basically go
04:43from there on an individual basis,
04:45but typically every five to 10 years.
04:48If there were no
04:50significant clinical symptoms at
04:52the time of colonoscopy.
04:55You mentioend that colonoscopy can be both diagnostic and
04:58therapeutic, talk a little bit more about
05:01the therapeutic options when you are doing
05:03a colonoscopy and you you find a lesion.
05:07First of all, what kind of
05:09lesions do we find in the colon?
05:12And secondly, how can colonoscopy
05:14be therapeutic in that regard?
05:17So the whole purpose of screening
05:20colonoscopy is to evaluate the person
05:23to see if they have developed any
05:25polyps which we know are precursors
05:27to most of the colon cancers,
05:29and most of those polyps can be removed
05:32at the time of colonoscopy and therefore
05:35never go on to progress to a cancer.
05:39We have seen that the incidence of
05:41colon cancer has dropped over the last
05:44few decades and we attributed that to
05:47screening colonoscopies and
05:49polypectomy's that have removed those
05:51potential future cases of cancer.
05:53So there are several types of
05:55polyps and they vary in size.
05:58Most of them can be removed
06:00endoscopically, some when they
06:02get larger when they are about 2
06:06centimeters or an inch get more
06:08difficult to be removed and should be
06:12removed by someone who has
06:15advanced endoscopic skills,
06:17these have the potential to have
06:22malignant transformation what
06:24we called dysplasia or possible
06:27early invasion and might need more
06:30advanced techniques to remove.
06:33And presumably some of these lesions
06:35may be flat and colonoscopy,
06:38even if you can't remove a polyp,
06:41can certainly biopsy potential
06:43cancers?
06:45Yes, if it is too large to remove safely,
06:49then it is generally
06:52biopsied and marked with ink as a
06:55tattoo and referred for surgery.
06:57We think that these polyps should be
07:00completely removed again because of
07:03their potential to progress to cancer.
07:06These lesions being flat are
07:08much more difficult to remove,
07:11and if they do develop invasion,
07:14malignant invasion,
07:15they are much more likely to spread
07:19faster than a more polypoid lesion.
07:23So let's suppose
07:26you've done a colonoscopy.
07:27You've either found a polyp that
07:30you couldn't remove completely,
07:32or you found a lesion that you've
07:35biopsied, in either of those cases,
07:38if cancer was found,
07:40that would mean that the
07:42patient moves next to surgery.
07:44Is that right?
07:47Typically yes. Again, depending on
07:51the skill and what you're feeling of
07:53the whole lesion is
07:57there are very advanced techniques
07:59where endoscopies will take the
08:01first layer off inside called
08:03endoscopic mucosal resection,
08:05which is adequate for very early
08:07stage cancers, but in general,
08:09most of those would be referred to a
08:12surgeon for removal of the whole area and
08:15evaluation of the regional lymph nodes.
08:18Now, before you do that,
08:20are there any kinds of advanced
08:22imaging tests that are required
08:24or blood tests to help you get an
08:26idea of the extent of disease?
08:30Well, certainly if you have a diagnosis
08:32of invasive cancer rather than something
08:35that's questionable or early stage,
08:37you're going to image them with
08:39a CAT scan to evaluate the liver
08:42for possible metastatic disease.
08:44It's been fairly commonplace to also
08:46do a CAT scan of the chest to looking
08:50for possible spread to the lungs,
08:52although that's much more common in
08:55rectal cancer than colon cancer.
08:59Blood tests the CEA or carcinogenic
09:01embryonic antigen is not produced
09:04by all tumors,
09:05but generally if you have a diagnosis
09:08of cancer you will check that if it's
09:11elevated it can be used as a marker
09:14later to follow the patient to see
09:17if there is recurrence,
09:19and so presumably if you've
09:21caught this cancer early because
09:23you started screening per the
09:26guidelines and now you you go and
09:28you have all of these tests and
09:30it doesn't look like there's
09:31cancer anywhere else,
09:33the next step is to remove that
09:35part of the colon that's got
09:37the cancer in it and evaluate,
09:39as you say, the regional lymph nodes.
09:42Now I understand that surgical
09:43techniques have improved over the last
09:46several decades and this can now
09:48be done in a minimally invasive way.
09:50Can you talk a little bit about that?
09:54Absolutely, so minimally invasive surgery
09:56the revolution started
09:58probably in the late 80s.
10:00Around 1990 we all started
10:03doing gallbladders that way and
10:05it reduced the incision size.
10:07Made recovery a lot faster, less pain and
10:10the patients were much more satisfied and that
10:13translated to colon surgery in the
10:17early 90s and there were several
10:20trials to determine whether or not that
10:24minimally invasive surgery was equal to
10:28conventional open surgery and a
10:30trial in 2004 and follow up of
10:34those patients over a long period
10:37of time proved that the cancer
10:40surgery was the same whether it was
10:43done minimally invasive or open,
10:45so the oncologic results were the
10:49same minimally invasive surgery,
10:51whether it be laparoscopic or robotic.
10:59It hurts a lot less.
11:01The recovery is faster,
11:04the patients are more satisfied with it.
11:08Bowel function tends to return faster,
11:11and as several studies over the years
11:15have shown it is oncologically
11:18the same as open surgery.
11:22One of the benefits though,
11:24is for people with more advanced surgery,
11:27more advanced cancer
11:28is that since they recover faster,
11:31they feel better.
11:32They're much more likely to go on and
11:35have chemotherapy if they need it
11:37after recovering from big open surgery,
11:39sometimes the people have had trouble
11:42and they just never get healthy enough to
11:45receive chemotherapy.
11:46So it sounds
11:48like we've moved into
11:50an era of of minimally invasive
11:52surgery for colon cancer,
11:54much like we have for Gallbladder surgery.
11:57But you mentioned two terms.
11:59One is laparoscopic and
12:00one is robotic assisted.
12:02Can you help our audience kind of
12:05understand the difference between the two.
12:08Sure, laparoscopy is something
12:10that's been around for a long time,
12:13and as I mentioned,
12:14the translation to more broad
12:16applications began in the early 90s
12:18and then into colorectal surgery.
12:20But basically what that is, is
12:23surgery inside the abdomen,
12:25done through several small incisions
12:28where you have instruments inserted.
12:30It's very good when you don't have to make
12:32a bigger incision to take a specimen out.
12:35In colon surgery,
12:36you have to make an incision that's
12:38probably 2 to 3 inches in size to
12:40get the piece of colon out with the
12:42lymph nodes in the tumor so that
12:44does have some pain associated with it
12:47when you do laparoscopic hernia's and
12:50you only have 3 or 4 little incisions,
12:54there's much less pain.
12:56Robotic assisted is attaching the
12:58robotic system to those instruments an
13:01that allows you much more dexterity,
13:03especially in smaller confined
13:05location like the pelvis when
13:07you're operating for rectal cancer,
13:10your visualization both laparoscopic
13:12and robotic assisted is
13:15a lot of times,
13:16much better than open because
13:18you have magnification.
13:20You have a light source that's
13:23right down there in his deep dark hole
13:27and you have your really dexterous
13:29instruments in a small space.
13:33And so certainly both laparoscopic and
13:35robotic seemed to be an advance over
13:38open surgery and allow you to get into
13:41small spaces with good visualization
13:43that you might not have had before and
13:46allow patients to get home sooner.
13:48We're going to talk more about
13:50robotic surgery and compare that
13:52to laparoscopic surgery and talk
13:54about what happens after the colon
13:56cancer surgery right after we take
13:58a short break for a medical minute.
14:00Please stay tuned to learn more about
14:03robotic surgery for colon and rectal
14:05cancers with my guest Doctor George
14:07Yavorek.
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15:01You're listening to Connecticut Public Radio.
15:06Welcome
15:06back to Yale Cancer Answers.
15:08This is doctor Anees Chagpar
15:11and I'm joined tonight by my
15:13guest Doctor George Yavorek.
15:15We are talking about treating patients with
15:18colon cancer with robotic surgery.
15:20Now right before the break we were
15:22talking about this whole evolution in
15:25minimally invasive surgery that really
15:27helps patients with colon cancer
15:30get that colon resected with minimal
15:32intervention, shorter hospital stays,
15:34less pain and so on.
15:36But George, the question that I often
15:40have is in terms of those metrics,
15:44getting home faster,
15:45amount of pain, blood loss,
15:48how long the operation is, and cost?
15:51How does robotic surgery stack up
15:54to laproscopic surgery which you
15:57know we all know has a number
16:01of advantages over open surgery.
16:03So the big thing I think would be
16:07patient satisfaction and patient
16:09satisfaction between both laparoscopic
16:11and robotic surgery is pretty equal
16:14because to them it's minimally invasive
16:16in terms of oncologic outcomes.
16:18Again, the same thing they've looked
16:20at that compared to open and obviously
16:23the standard is open surgery,
16:25but the oncologic outcomes are the same in
16:28terms of all the parameters that we look at.
16:32Some of the other things you
16:35mentioned though were the big
16:37knock on robotic surgery is cost.
16:39And the expense of the equipment.
16:42What happens with that?
16:44Is it can be actually cost effective
16:46because the patients tend to
16:49stay in the hospital less time.
16:51If you have them on what we call
16:54an ERAS, enhanced recovery
16:57after surgery protocol,
16:59which typically a lot of specialties
17:01are using for urology, gynecology,
17:03colorectal surgery and that goes from the
17:06pre op preparation through the surgery,
17:09anesthesia and into the postoperative period.
17:12These patients are spending
17:13less time in the hospital.
17:15They are back to normal faster.
17:18They are feeling better and
17:20there are actually less
17:22complications and problems which
17:24cut down on hospital costs.
17:26So those are things that can negate the
17:29extra expense of the robotic surgery
17:32and actually make it cost effective.
17:35So let me push back a little.
17:40Understandably, ERAS protocols
17:41would improve all of those metrics,
17:43whether the surgery was open,
17:45patients who are on any rest protocol,
17:48who have open surgery would do better
17:51than people who are not.
18:00So I can understand how that
18:03protocol can reduce the length of stay for
18:06patients who are having robotic surgery.
18:08But given that robotic surgery
18:10and laparoscopic surgery are
18:12both minimally invasive,
18:13and robotic surgery is much more expensive
18:16if you have patients who have laparoscopic
18:19surgery who are on an ERAS protocol
18:22and patients who have robotic surgery
18:25who are on an ERAS protocol,
18:31are there really any differences
18:34in terms of length of stay,
18:36length of hospital time,
18:38length of surgical procedure,
18:40blood loss that are different between the
18:43laparoscopic group and the robotic group?
18:46That would tend to favor one over the other.
18:52So if you look at it across the board just
18:55comparing laparoscopic for robotic surgery,
18:58typically the outcomes are
18:59going to be very similar.
19:01They're going to be about the same.
19:04Robotic surgery would be more
19:06expensive because of the equipment
19:09part of the problem becomes the
19:11skill level of the surgeon.
19:13Where robotic surgery makes it
19:16easier for most surgeons to do
19:18more complex operations.
19:22The inexperienced laparoscopic surgeon
19:24could probably do about the same things
19:28that a robotic surgeon does, and
19:31most people are well versed in both,
19:34but I think you're correct in that
19:38across both procedures
19:40it's going to be less expensive for
19:43laparoscopic surgeon and the results
19:45are pretty much going to be the same.
19:49Part of the idea behind the robotic
19:51surgery is that it takes more
19:54open cases and makes them minimally
19:56invasive across the country.
19:58At least 50% of the colectomies
20:00are still done
20:02through a traditional incision,
20:04only about 50% are done
20:05minimally invasively and of those the vast
20:08majority are still done laparoscopically.
20:10It's somewhere between 5 and 10%,
20:13are done robotically the other 40% are
20:15done laparoscopic and the other 50%
20:18are still done through an open incision.
20:21So the penetration is
20:23increasing for robotic surgery,
20:25but back to the question, I think that
20:30all things given certainly
20:32laproscopic surgery is more
20:35cost effective than robotic surgery.
20:37So I guess what I'm getting from
20:40you is that robotic surgery may be
20:42a good option for some cases where
20:45you really don't think that you would
20:48be able to do this laparoscopic
20:51but given the dexterity that you can get
20:54particularly low down in the pelvis,
20:57which would otherwise mandate an open
20:59surgery, robotic surgery might have an
21:01advantage in that realm over
21:04laparoscopic is that right?
21:06Yes, I agree with that.
21:08And in complex surgery so
21:10not only for colon cancer,
21:11but if it's a complex cancer that may
21:14be attached to the bladder of the
21:17uterus and even non cancer surgery
21:19like complex diverticular disease,
21:21I think the robot is an advantage
21:24over laparoscopic surgery and the
21:26one thing is that conversion rate
21:28is lower for robotic surgery.
21:30So if you look at it in that
21:33light robotic surgery has an
21:36advantage over laparoscopic surgery
21:38because the conversion from
21:39minimally invasive to open surgery,
21:42which adds more to cost and
21:44actually increases hospital stay
21:46for someone who's gone through
21:48an open incision to begin with,
21:51the robot does decrease the chance
21:54of conversion and therefore is an
21:57advantage in those situations,
21:58so you
21:59know with people who have expertise in
22:02both laparoscopic and robotic surgery,
22:05how do you decide which procedure
22:07to offer your patients?
22:09Or are you offering all of them one
22:12particular route as a first choice?
22:16I think it depends on a few things.
22:18Depends on the complexity,
22:20location of the tumor.
22:21If I feel that, especially rectal
22:23cancers, down in the pelvis,
22:24I really like the robot down there
22:27again because of the confined
22:29space and the ability to get down
22:32there with good visualization.
22:34If the person may be someone
22:37who I'd like to get in and out
22:40of surgery a little bit faster,
22:42an older person with a lot of health issues,
22:45I may choose to do it laparoscopically,
22:48because generally the times
22:50for those surgeries are less, so
22:52it's an individual basis.
22:54I offer all my
22:56patients one or the other.
22:59And the other question that
23:01many of our listeners may have
23:03especially thinking about
23:04the cost of robotic surgery
23:06is, is it covered by insurance?
23:10Generally speaking, there's no cost to
23:13the patient that if there is a cost,
23:16the hospital ends up absorbing it
23:18because they can't pass that on to
23:22the patient. The insurance company
23:24doesn't always reimburse more
23:25for a specific procedure,
23:27but the hospital has figured out a
23:30way to in terms of making things more
23:33efficient to make these cost effective.
23:37And it sounds like if
23:41the patient costs are all equal and
23:44oncologic outcomes are all equal,
23:47then it sounds like the real cost
23:50is to the health care system.
23:53And that's something that health care
23:55systems will need to figure out
23:58now if during that staging work up
24:01needed before the the surgery itself,
24:04let's suppose you did find a
24:07little metastasis to the liver,
24:10can you take that out at the same time as
24:13you do the colon surgery with the robot?
24:17Yes you can. The paddle biliary
24:19surgeons are doing liver resections
24:22laproscopically and robotically
24:24so you can do that if it's the
24:27right thing to do at that time.
24:33Sometimes it's removed at
24:35the same time in the surgery.
24:37Sometimes they get chemotherapy first
24:39to see if it progresses or regresses,
24:42or new lesions pop up so, but it can be done
24:47minimally invasive, yes.
24:49And so it sounds like you know,
24:52there have been so many great advances on
24:55the surgical front once patients go home.
24:58You mentioned that one of the advantages
25:01of minimally invasive surgeries that
25:03they can actually get onto their adjutant
25:06systemic therapy, their chemotherapy
25:08a little bit quicker there.
25:10After some older patients may
25:13have difficulty in that post
25:15operative period recovering and
25:17so delay or potentially dismiss
25:19their chemotherapy.
25:20Can you talk a little bit about
25:23whether all patients with colon cancer
25:26require chemotherapy after surgery,
25:28and whether there have been
25:30any advances in that regard?
25:33So not all patients require chemotherapy.
25:36Cancer is staged one through 4.
25:40Obviously one being very early
25:42in those patients. Generally,
25:44surgery alone is curative between 90-95%
25:47of the time they do not require
25:51chemotherapy , it does not add to their cure rate.
25:56Stage two is the big gray zone.
26:00That's a very large stage,
26:02and some of those patients,
26:04depending on individual tumor characteristics
26:07may benefit from chemotherapy.
26:09They may be at a higher
26:11risk to develop recurrence,
26:13and that's something that has really
26:16progressed over the last 10 years.
26:18Our evaluation of individual tumors
26:21and what those individual tumor
26:23characteristics mean in terms of prognosis.
26:26Stage three,
26:27there are lymph nodes involved and those
26:30people are all candidates for chemotherapy,
26:33which has been shown to have a
26:38significant improved survival.
26:39And stage four is distant metastases
26:42and generally chemotherapies
26:44are used there too.
26:45Also in more of a palliative manner,
26:49and as you kind
26:51of mentioned and briefly talked about,
26:53in that stage two discussion have there
26:56been advances in terms of chemotherapy?
26:59I mean the robotic surgery,
27:01getting to minimally invasive surgery
27:04really seems to be advantageous in
27:07terms of fine tuning surgery to an
27:10individual patient and you talked
27:12a little bit about how you tailor
27:14the surgical management
27:16according to patients,
27:18has that filtered into the
27:21medical oncology management as well?
27:25Yes, most people will get
27:28a combination of chemotherapy drugs,
27:31usually two or three, and generally
27:33it's tapered to their situation,
27:35their age, their medical comorbidities,
27:37and also the tumor itself.
27:40As I mentioned,
27:41they do several analysis of the tumor,
27:44and there are some studies that can tell
27:47you whether or not they will respond
27:50to a particular chemotherapeutic agent.
27:52And as with a lot of medicine that's gotten,
27:57rather involved and complex over the
27:59last few years and most people will
28:02end up with an oncology consultation
28:04and the medical oncologist
28:06will tailor their therapy to that.
28:10Now the third arm of the
28:12stool is always radiation.
28:14Do colorectal patients require
28:16radiation after surgery as well?
28:19So radiation is generally used for
28:21rectal cancer, not colon cancer.
28:23When it's out of the pelvis,
28:25there's generally not a role for radiation.
28:28It's when it's in the fixed
28:30confines of the pelvis that
28:31radiation is used.
28:33It's not used all the time,
28:35and we do a lot of work up
28:37and staging before hand,
28:39and a lot of times radiation is
28:42given with chemotherapy before
28:44surgery for rectal cancer to shrink
28:46the tumor and allow
28:49for preservation of these sphincters
28:50so you don't have a permanent
28:53ostomy bag.
28:54Doctor
28:54Georgia Yavorek is a clinical instructor
28:57of surgery specializing in gastro
28:59bariatrics at the Yale School of Medicine.
29:01If you have questions,
29:03the address is canceranswers@yale.edu
29:05and past editions of the program
29:07are available in audio and written
29:09form at yalecancercenter.org.
29:10We hope you'll join us next week to
29:13learn more about the fight against
29:16cancer here on Connecticut Public Radio.