Multidisciplinary Management of Colorectal Cancer

Additional Info

• Audio File:uab/ua157.mp3
• Doctors:Kennedy, Greg
• Featured Speaker:Greg Kennedy, MD
• CME Series:Quality and Outcomes
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4118
• Guest Bio:Dr. Kennedy graduated from the University of Washington School of Medicine and received his PHD in cancer biology from the University of Wisconsin where he also completed his general surgery training. 
  
  Learn more about Greg Kennedy, MD 
  
  Release Date: August 13, 2020
  Expiration Date: August 13, 2023
  
  Disclosure Information:
  
  Gregory D. Kennedy, MD, PhD, has no financial relationships related to the content of this activity to disclose. Also the planners, Ronan O'Beierne, EdD, MBA, and Katelyn Hiden, have no financial relationships to disclose.
  There is no commercial support for this activity.
• Transcription:UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
  
  Melanie Cole (Host):  As treatment strategies for patients with colorectal cancer advance; there has now become an ever increasing need for multidisciplinary teams to care for these patients. Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re discussing the multidisciplinary management of colorectal cancers. Joining me is Dr. Greg Kennedy. He’s a Professor of Surgery, the John H. [00:00:56] Chair in General Surgery and the Director in the Division of GI Surgery at UAB Medicine. Dr. Kennedy, it’s a pleasure to have you join us again. Tell us what you’re seeing in the trends for colorectal cancer, before we get into some of the treatment options.
  
  Greg Kennedy, MD (Guest):  Well there’s a lot of good things happening in colorectal cancer Melanie. So, first, colorectal cancer is the third most common cancer diagnosed in both men and women in the United States. So, it remains a really important problem. However, the incidence is decreasing over time recently in certain populations. Which is a great thing. We think that’s because of a combination of factors probably increased screening and detecting the tumors at earlier rates. But there remains reason to be cautious. There is some evidence that there is worse outcomes still in our minority populations and we also have some evidence that it’s increasing in incidence in the younger patient populations.
  
  So, while there’s some positives in colorectal cancer, there remains some certain challenges that we still have to be aware of.
  
  Host:  Is there anything new and exciting as far as screening?
  
  Dr. Kennedy:  Well some – new and exciting is always relative isn’t it. But certainly, colonoscopy remains the gold standard I would say for screening. But we certainly have some newer tests that have hit the market in recent years, in the last five or ten years with the FIT test, the fecal immunochemistry test that is looking for small quantities of blood and also some of the DNA testing, DNA-based tests made by some companies around the country that have been approved. Now these tests are good for detecting cancer, not necessarily good for detecting polyps. So, colonoscopy remains the gold standard.
  
  But I think that the newer tests do increase access to screening for patients in the more rural communities who perhaps don’t have availability of providers that do colonoscopies so, I think there’s some real positives there.
  
  Host:  There certainly is. That’s so interesting. So, now let’s talk a little bit about the multidisciplinary management of colorectal cancer. Why is this so important? Is it new Dr. Kennedy? Has it always been this way?
  
  Dr. Kennedy:  Multidisciplinary management of cancer in general, has really been pushed in the major medical centers over the last ten to fifteen years. It’s been hypothesized that this multidisciplinary care would enhance preoperative evaluation, give patients increased access to specialists and multimodal therapy. And in fact, it’s been shown to do that in many other cancers beside colorectal cancer. Pancreas cancer, lung cancer, breast cancer, et cetera and in those treatment pathways, they’ve seen- we’ve seen the adaptation of multidisciplinary care really become the standard of care. This is where patients are seen and evaluated by a group of specialists from different fields, medical oncology, radiation oncology, and surgery. Colorectal cancer, it’s not necessarily been the standard of care until recent times. Some of that’s been the advent of the American College of Surgeons bringing forth the National Accreditation Program for rectal cancer that’s really put a spotlight on multidisciplinary care and some of the inadequacies of rectal cancer care in the country and here in the United States.
  
  These are patients who are being treated without the multimodal approach. So, not getting the appropriate staging preoperatively, not getting the appropriate treatment preoperatively, being rushed right to surgery. It’s pretty clear that that approach, that sort of rushed approach has worse outcomes. So, definitely, this more multidisciplinary care has become more and more popular and it’s really the standard of care here at the University of Alabama at Birmingham.
  
  Host:  So, then tell us what that looks like for your team Dr. Kennedy. Who are the primary multidisciplinary team members?
  
  Dr. Kennedy:  Well we – like everyplace, we have a – like everyplace that does this, we have a diverse group. We use radiation oncologists, the medical oncologists, the surgical oncologists as well as the colorectal surgeons. We all participate. We’ve got a very robust group here. When a patient receives a new diagnosis of colorectal cancer and presents to our clinic; they will see all three providers in that visit. This is really just streamlines the visit for the patient. However, while the patient might see that, and they see this as a streamlined process, very convenient; what they don’t see is all the work that goes into this and that’s where I think the value is in this multidisciplinary approach.
  
  Before the patient ever gets there, we are receiving the tests, any tests that the patients have had. We’re discussing the patient’s care as a group. We’re really coming up with a plan before we ever see the patient. So, that way, when we go in, we can talk to the patient, sort of a directed focused discussion, learn from the patient anything that we may not already know about them in particular that we may not have already learned from their outside documents, really be able to tailor the plan specifically for each patient. This is I think just a fantastic approach to care. It really leads to not only streamlined care but really high value and highly satisfied patients. So, it’s been really a great introduction of a care team and a care pathway here at UAB.
  
  Host:  Dr. Kennedy, this may seem a difficult question but as we see improved coordination of care, and the opportunity to assess each patient as you’ve described from many viewpoints, and that’s really an immediate benefit for the patient for sure and that multidisciplinary team; tell us some of the challenges of this. Is there sometimes a differing of decisions regarding the choice of treatment? Tell us a little bit about some of the challenges that you’ve overcome at UAB in this form of care.
  
  Dr. Kennedy:  Yeah. That’s a great question Melanie and there’s no doubt there is a differing of opinions in how patients should be treated. And that’s the great thing of working together as a team and knowing the team members as well as we know each other. We can actually debate. We can look into the literature. We don’t always have the answers, do we. We have to sometimes look into the literature, find out what is the right answer and oftentimes, if we’re debating it, there is no right or wrong, so it comes down to what the team decides then and quite honestly, majority rules. We’ve had patients – I’ll just give you an example. A recent patient who had extensive lymph node involvement from their rectal cancer. We talked a lot about doing surgical therapy of those lymph nodes versus more radiation therapy. Ultimately decided on radiation therapy because of some concerns of increase morbidity of surgery. The surgeons didn’t necessarily agree, but the majority felt that the increased morbidity of the surgical therapy outweighed the increased morbidity of radiation therapy. So, we went with radiation. So, that was a great example of how having a multidisciplinary approach led to actually an improved outcome of the patient. Because at the end of the day, the patient had a complete response in the lymph nodes from the radiation therapy and is doing quite well six months later. So, it’s been those sorts of conversations that allow us to have – that we are allowed to have because of this approach, and we can really come up with some great tailored treatment plans and I think improved outcomes, ultimately.
  
  Host:  Well that’s such a great example and a good point. But along those lines, for effective management of certain cancers, and they remain great challenges for the surgeon, yes, so with increasingly complex treatment algorithms that you are finding these days that add new options to your armamentarium of available therapies; is there somebody in charge? Is the surgeon in charge of guiding the patient’s care? Tell other providers as you say you’ve all known each other for a long time and you work together so well; but how are those decisions made?
  
  Dr. Kennedy:  Yeah, well that’s a great question. And we always as surgeons, we always like to think we’re in charge, don’t we? But the truth is that’s not the way we see it. this is very much a team approach and in fact, we tend to view this as the patient is in charge. We want to give the patient the information they need to make an informed decision and then let the patient make the decisions that are necessary. So, we try our best to guide the patients with the right information and let the patients make the decision that fits them best.
  
  And I think that’s again, the beauty of multidisciplinary care. So, the idea that one person is in charge, I think is not necessarily true. We really view this as a team where all voices are important and all voices are equal and our goal is to give the patient the best treatment option that we’ve all agreed on in one way or another and then provide the patient with some options along those lines, trying to say what we think is the best but hear others that could also work and then ultimately let the patient make the choice that they’re comfortable with, assuming the outcomes are close to equivalent.
  
  Host:  What a comprehensive approach. Is there anything you’d like to share as far as research at UAB that other providers may not know about?
  
  Dr. Kennedy:  Well we’re always trying to use our patients in a way that we can advance the science of the disease as well. We’re always interested in trying to understand the genetics of cancer so we have various genetics studies looking at the heterogeneous nature of cancers and how that heterogeneity of a cancer might lead to better or worse outcomes. So, we know that tumors that differ within the cancer sometimes have certain populations of cells that may give rise to metastatic disease. We’ve been interested – we’ve got a research group interested in understanding that heterogeneity and what it means to patients. So, that’s certainly one area of research that we have going on. We also have an area of trying to understand staging. So, currently, the only way we can accurately stage a patient is by doing surgery and taking lymph nodes out. We’re trying to put forth a protocol whereby we stage patients with MRI before we ever operate on patients and really be able to accurately stage patients.
  
  This would lead us if we could accurately stage patients, it would lead us to more informatively move down a watchful waiting type pathway for rectal cancer. So, in those patients who have a complete response, if we can have evidence that they truly have had a complete response in their lymph node basin, using MRI, we can then feel better about a decision of watchful waiting. So, certainly we have these various research protocols that are always open and we’re trying to enroll patients to advance the knowledge of the disease.
  
  Host:  Well thank you for telling us about those exciting advances and trials that you’re running there at UAB. As we wrap up, please summarize for us Dr. Kennedy, what your outcomes have looked like as a result of a multidisciplinary team approach and the benefits of this type of approach for not only the patients but for the surgeon and the other team members involved because it gets you all involved and you all know what each other is doing and you really get to bounce things off of each other.
  
  Dr. Kennedy:  Yeah. I think the benefits are multiple Melanie so, first the multidisciplinary management of colorectal cancer has been associated with significantly more complete preoperative evaluation as well as improved access to multimodal therapy. That’s pretty clear. And we’ve seen that in our own practice. We also have seen just improved patient satisfaction. The patients who are coming to these visits are having a great experience. They are certainly coming with complicated problems but in trying to meet all the providers in one appointment and then leaving with a clear idea of what’s happening and where they are going next. They are leaving much more satisfied and having a much better experience.  
  
  I think those are absolute benefits. From a personal and professional perspective, it’s just led to such a great team approach and such great camaraderie with the team that I can’t imagine going back to another way of treating the disease. So, I think it’s fantastic and we really love treating patients and helping patients in this situation. So, hopefully we will continue to grow the program.
  
  Host:  Thank you so much Dr. Kennedy for joining us today and sharing your incredible expertise. And what an exciting time to be in your field. Thank you again and a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB podcasts. I’m Melanie Cole.
• Hosts:Melanie Cole, MS