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Melanie Cole (Host):  Welcome to Back to Health, your source for the latest in health, wellness, and medical care; keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world renowned physicians at Weill Cornell Medicine. I'm Melanie Cole, and I invite you to listen as we discuss colorectal cancer treatments today. In this panel, joining me is Dr. Heather Yeo. She's a Frank Glenn Faculty Scholar in Surgery, Dr. Joseph Ruggiero. He's a Professor of Clinical Medicine at Weill Cornell Medicine and Dr. Encouse Golden. He's an Assistant Professor of Radiation Oncology, and they're all with Weill Cornell Medicine. Doctors, thank you so much for joining us today. And Dr. Ruggiero, I'd like to start with you. Give us a little background on colorectal cancers, the prevalence, and then start with us about how it is staged. How do you see how far along someone is in their progression of these types of cancers?

Joseph Ruggiero, MD (Guest): Well, thank you for that question. Colorectal cancer is relatively common, unfortunately, often detected at the time of a routine colonoscopy or because of symptoms of rectal bleeding or abdominal pain. It's important to know that the demographics of this cancer is changing a bit. Meaning that we're beginning to see it in younger patients, and in fact, recommendations for screening for this cancer have changed recently. And we now recommend screening for patients without a family history to start five years earlier than we used to at around age 45.

Once this diagnosis is made, staging is an important process because it determines how we treat the patient. It always starts with a CAT scan of the chest, abdomen and pelvis to make sure that the cancer has not spread to any organ in the body other than the colon. Further staging is different for colon and rectal cancer. And it's important to understand that we deal with colon and rectal cancers differently. So, the rectum is the last 10 to 12 inches of the colon. And in addition to CAT scanning, we generally will need an MRI of the pelvis to assess the tumor, its depth of penetration into the wall and whether any lymph nodes are involved. And the reason for that is that these patients are often treated with radiation or chemotherapy prior to surgery. In cancers above the rectum, following the CAT scan, patients generally go to surgery and final staging is based on the pathologic analysis of the tumor and the regional lymph nodes.

Host: Well then Dr. Ruggiero and thank you for that summary. The focus for these patients is a multidisciplinary team. Tell us what that looks like for the team and why it's so important for these patients.

Dr. Ruggiero: Absolutely. all cancer treatments in the last 20 years, this has been the biggest advance is that we now understand that the best outcomes, the highest cure rates with the least toxicity occur with more than one modality of treatment for many patients with cancers. So, surgery alone may not give the best outcome. Treatment often requires chemotherapy or radiation or some combination of the three. And it's important that this decision and this treatment plan be made prior to starting treatment. And so, we treat these patients as a team. We include pathology, radiology, radiation therapy, surgery, and medical oncology. We sit together, we analyze the data and then we make a treatment plan, which is very often multidisciplinary.

Host: And Dr. Golden, why don't you tell us your role in this? Speak about the benefits or advantages or disadvantages of radiation treatment, whether we're talking about short course versus long course. Tell us a little bit about radiation treatment and what patients can expect.

Encouse Golden, MD, Ph.D. (Guest): Thank you for asking that question. So, we have come into the paradigm of total neoadjuvant therapy, which includes preoperative radiotherapy and multiagent chemotherapy. And this allows for an improved adherence to treatment, higher rates of tumor down staging, and lower rates of disease related treatment failures. In addition, there have been shorter intervals from illeosteomy to reversal as well as the potential for organ preservation, if a complete or near complete response is obtained for these patients that are getting this type of treatment. This total neoadjuvant therapy, which includes again a combination of radiotherapy with chemotherapy, has traditionally been completed with a course of about five to six weeks of treatment. This has been sort of the paradigm that has been used here in the United States. However there's additional treatments, including a shorter course regimen of one week of radiation followed by chemotherapy. Again, these two treatments are done prior to surgery, and it improves the surgeon's ability to resect the tumor. Now, the five to six week regimen of chemo, radiation it is somewhat inconvenient for patients, where they're coming in for daily treatments within the radiation oncology department. A short course of one week of radiation allows for an acceptable alternative for patients to complete their treatment much sooner. So, it's a lot more convenient. But in terms of the outcomes, there is equipoise between the two. And we believe that patients, you know, if they select one versus the other, their outcomes will be similar.

Host: Well, Dr. Golden, then what's exciting as far as MRI guided treatments for rectal cancer, and then speak a little bit about how rectal cancer management is a little different. And that it can be treated with radiation, some of the challenges. Speak about that and kind of tie this all together for us based on what you do and how you help these patients.

Dr. Golden: Absolutely. So, we at Weill Cornell have MRI guided radiation therapy machine. It's called a MRIdian and it basically just stands for MRI, for the first three letters of MRIdian. And it is a promising technology, that helps to facilitate safe tumor dose escalation, meaning that we can increase the dose safely to the primary tumor to further optimize preoperative rectal cancer therapy. Now the MRI guided machine, in general is used for shorter course regimens, such as the five dose fraction regimen, whereby we can target the tumor, and limit the amount of side effects that occur with that particular therapy. Now there's growing interest across multiple institutions that have this MRI guided machine whereby we can do MRI adaptive planning.

So, this is a real time adaptive planning while the patient is on the machine and we can change the plan based on the location of where the tumor is located in respect to the bladder and for depending on gender, for men, the prostate and for women, the uterus and the vagina. So, this type of technology will allow for a reduced amount of toxicities during the course of the treatment, provide for a shorter treatment for these patients and hopefully, actualize better responses including those that have a complete response.

Host: Isn't that fascinating, what you're able to do today with this multidisciplinary approach? And while we are talking about that, Dr. Yeo, on to you, tell us a little bit about what happens afterward. If someone has had this combination therapy, whether it's neoadjuvant or surgical or radiation oncology, whatever it is; what is the followup care because these particular types of cancer can affect the quality of someone's life in dramatic ways. So, speak about what patients can expect after surgery, after rectal surgery, colon surgery, what is it like for them?

Heather Yeo, MD, M.H.S., M.B.A. (Guest): Thanks so much, Melanie. Yeah, you're exactly right. You know, these treatments are not without consequences. Patients generally do very well after surgery. But there are some long-term effects and I'll kind of go through some of those. And I also, I know in one of our previous podcasts, you've talked a lot about the procedures, the procedure you had does impact your recovery. So, I'm just going to briefly mention that. More often now we're doing minimally invasive surgery, laparoscopic or robotically, and those patients if they're able to have minimally invasive surgery, depending on their cancer, usually their recovery is a little bit quicker. If they have standard open surgery, they do recover just as well, they just may be in the hospital for a little bit longer. It generally takes patients, the average length of stay for a surgery for colon or rectal cancer in the United States is somewhere between three and seven days. With the average length of stay about five days. And patients do have changes in the immediate post-operative period.

They often have fatigue, appetite changes, and they often have changes in their bowel habits. It depends again, a little bit on the procedure type. If it's standard colon surgery, then most patients get back to typical normal GI and bowel function. But if they have a colostomy or an ileostomy, they can have different function or if they have low rectal cancers, they often do have some lifetime effects. In terms of monitoring these patients, we usually see them pretty frequently as they're initially recovering after surgery. And then we space it out. And as we talked about earlier, this is really a multidisciplinary process. So, over the next several years really focused on the first two, because that's the most common time that a cancer can come back, we'll see them in conjunction with the medical oncologist and the radiation oncologist every three to six months. So, we follow them very closely for those first two years after surgery.

Host: Dr. Yeo, if a patient has to have a colostomy or ileostomy, what is life like for them afterwards? It could be quite a scary prospect. Tell us a little bit about it.

Dr. Yeo: Yeah. So, for some patients who have colon surgery, they end up needing either a temporary or permanent colostomy. And a colostomy is when the colon is brought up through the abdominal wall, or an ileostomy where it's small bowel, that's brought up through abdominal wall. You know, their bowel function is different, but patients really do things like they normally would. There's an initial period of adjustment, but, these patients are able to work. They're able to you know, play and exercise and they're able to have and engage in active sexual life. So, there's a lot of misconception around that and people get really nervous and upset, but quality of life in these patients long-term is very high.

Host: So, then tell us a little bit about what's different after rectal cancer surgery.

Dr. Yeo: So, in rectal cancer surgery, if patients are able to be connected, they're missing their rectum and their rectum is what is used for storage. And so they do often have some altered bowel function, meaning they often have some frequency or urgency. Most of the time, this is most bothersome in the first two years after surgery and gets much better after that, but they can have some lifelong symptoms. So, it's important that they talk to their surgeon or their medical providers, because there are things that we can do to improve their quality of life.

Host: What a great summary Doctors. So, I'd like to give you each a chance for final thoughts to let listeners know what they can expect, to kind of reiterate and reinforce this multidisciplinary approach. So, Dr. Ruggiero I'd like to start with you. What would you like listeners to take away from this podcast as you are a professor of clinical medicine and you're involved in start to finish. Tell us what you would like patients to know about colorectal cancers and how you can help them at Weill Cornell Medicine.

Dr. Ruggiero: Well, I think the you know, the advancement in the last five or 10 years in our understanding of colon cancer and in treating it with a combined approach have led to marked improvements in outcome, with reduction in toxicity. So, most patients with colon cancer are going to require surgery. And then a decision regarding preventative chemotherapy. The preventative chemotherapies after colonic surgery has dramatically improved the cure rates from the surgery. Patients with rectal cancer may require what Dr. Golden described as preoperative chemotherapy and radiation to shrink the tumor and prevent spread before the surgeon even operates. And this has led to improvements in outcomes for this cancer as well.

We're working on newer treatments to prevent recurrence. We have an exciting new clinical trial trying to determine which patients benefit from chemotherapy and following surgery. And we're trying to refine postoperative chemotherapy and that's going to lead to improvements in outcome as well. So, I think in every way, things have gotten better and I'm old enough to have seen these exciting changes.

Host: Well, it certainly is an exciting time to be in your field and Dr. Golden, what would you like, and I think an important aspect for your profession is to explain to the listeners about radiation oncology and how this type of adjuvant therapy really works hand in hand with all of the ones that we've heard about and this multidisciplinary approach.

Dr. Golden: So, over the past five to 10 years, there have been efforts to be much more precise in the way in which we're delivering our treatments, including radiation therapy. And that precision includes, ensuring that we're sparing the normal organs while focusing the radiation on our target, including at risk areas of disease within the pelvis, and the primary tumor that's seen on any particular imaging. So, our field is pushing the envelope in terms of improving precision in terms of the delivery of the radiation. So, the technology has definitely improved. So, patients in the next five to 10 years, will be able to benefit from those advances that have come about most recently. And there may even be additional studies looking at the combination of other types of radio sensitizers, to improve the complete response rates for these patients. So, there's a lot to look forward to.

Host: Well, there certainly is. And Dr. Yeo, last word to you. What would you like the listeners to take away from this message about colorectal cancers, awareness, prevention, screening. I'd love for you to tie it all together for us.

Dr. Yeo: So, I think the number one thing that I'd like individuals listening to the podcast to take away is that we've made progress. That there's hope. That after people recover from colon cancer, oftentimes they go back to very good quality of life, very good function. I think you talked about it in some of the earlier podcasts. One of the things that people can do if they have not had colon cancer, is that they can focus on prevention. And we know that colon cancer is higher in individuals who smoke. We know that it is higher in individuals who are overweight. So, focusing on weight is important. We know physical activity helps improve outcomes. Patients having a high fiber diet are less likely to have colon cancer. And as you talked about in the last podcast, one of the most important things people can do is keep up with their screening. We know that screening and removal of polyps, early polyps, precancer polyps, prevents cancer. And so it is really important that individuals particularly in a pandemic, make sure that they maintain their preventative healthcare.

Host: Such important information and advice. What an informative episode, thank you all for joining us today. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits. And you can be confident of your appointments and the safety at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to thank our listeners and invite our audience to download, subscribe, rate, and review Back to Health on Apple podcast, Spotify and Google podcast. For more health tips, go to weillcornell.org and search podcasts. And parents, please don't forget to check out our Kids Health Cast. I'm Melanie Cole.