Defeating Colon Cancer with Surgery Recorded on: September 19, 2012 Alessandro Fichera, M.D. Director, Colorectal Surgical Oncology Program, Seattle Cancer Care Alliance Please remember the opinions expressed on Patient Power are not necessarily the views of Seattle Cancer Care Alliance, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. Hello and welcome to Patient Power, sponsored by the Seattle Cancer Care Alliance. I m Andrew Schorr. I know in our family we ve been affected by it all too much, colon and rectal cancer. We have had two family members with those cancers, and so all of us, as we get older as adults, are very careful to be screened for those cancers, and we hope you follow those guidelines as well. We re delighted to have as our guest today, the new Director of the Colorectal Surgical Oncology Program at the Seattle Cancer Care Alliance, and that s Dr. Alessandro Fichera. Dr. Fichera, welcome to Patient Power. Thank you for having me. Dr. Fichera, help us understand how colon and rectal cancers develop and how surgery can be lifesaving. Up to a few years ago we thought we knew exactly how colon and rectal cancer develops. A small polyp becomes a bigger polyp, and then that polyp becomes cancerous. While this is still the majority of cases we see, there are several other pathways for cancer development.
There is clearly a pathway where we don t see those polyps that are so obvious when a colonoscopy is done, because they are flat lesions. They are more difficult to identify, and those are the cases with genetic predisposition. They probably account for less than 20 percent of the cases we see these days. And then we have the cases associated with inflammatory bowel disease where the presentation could be very difficult to detect due to the changes of the disease itself. A patient with Crohn s disease, with a very abnormal mucosa, is very difficult to diagnose with colon and rectal cancer. However, the majority of patients still present with the typical polyps that we can see when we do an endoscopy. There are several steps to prevent a widespread presentation. Number one is regular colonoscopy. We all know that average-risk patients should all have a colonoscopy by age 50. And patients with a family history or genetic predisposition should have a colonoscopy by age 40 at least if not sooner, depending on their genetic background. Those maneuvers can prevent a majority of these cases. If a patient presents already with an invasive carcinoma, surgery plays a major role, and surgery clearly is extremely important in the management of rectal cancer where following the proper surgical procedures makes a difference in terms of long-term cure and survival. Dr. Fichera, what are some of the latest advances when it comes to diagnosing and treating colon and rectal cancers? The advances have been in several fields, and I ll try to be brief, but I can really spend a lot of time talking about this. We can start from the endoscopy. There are several new technologies that allow us to see better, even those flat lesions, in terms of manipulating the light, the intensity of the light, the color of the light, staining of the mucosa that allow us to see even the earliest lesions. In the medical and radiation treatment there are several advances that make treatments way more effective than just five to 10 years ago. And lastly, surgery, which is what I do, minimally invasive surgery has been proven to be as effective as open surgery for colon cancer, and there are studies going on as we speak that are trying to demonstrate the same efficacy of minimally invasive surgery for rectal cancer as well. 2
The advantages of minimally invasive surgery for colon and rectal cancer is the fact that recovery is a lot faster, patients are ready to undergo further treatment sooner if they need further treatment than with open surgery, because indeed the recovery is faster and the complication rate is significantly less. So we re able to treat our patients as effectively and get them ready for any next step necessary much faster. What are the success rates for these procedures if the cancer is discovered early enough? If discovered early enough, let s say a stage 1, in both colon and rectal cancer, the five-year cure rate is in excess of 90 percent. There are people that see the glass half empty and others see it half full, but with 90 percent, there is really one way to look at it, and that is the glass is pretty much full. As the stage progresses obviously these numbers go down a little bit, but again with very effective chemo and radiation therapy we are able to achieve a five-year cure rate even for stage 3 cancer that is as high as 70 to 75 percent. And the key is having a multidisciplinary team. You re the surgeon, there s a pathologist, a radiation oncologist, a medical oncologists, all working together? Well, the key these days is a multidisciplinary team that allows us, not just the surgeons but the whole team, to understand what would be the best first step, the timing of surgery if surgery is part of the treatment process, and also what to do afterwards. So there shouldn t be any colon or rectal cancer in the United States that is not treated by multidisciplinary team. Doctor, earlier you mentioned inflammatory bowel disease, ulcerative colitis and Crohn s disease. I would imagine that patients with those conditions should be monitored more carefully because they may have a higher risk of colon and rectal cancers. These patients are typically young. There are two peaks of incidence for this disease. One is in the second to third decade of life, so very young patients start dealing with the disease very early, and the longer you have the disease the higher is the risk of cancer. We know this for ulcerative 3
colitis. We ve known this for ulcerative colitis for a long time. We are learning that it is true also for Crohn s disease as well when it involves the colon. So we re dealing with a young patient population with a chronic disease, and we are able to control it but never completely cure it. We can put them in remission for a very, very long time, sometimes for their entire life, but the risk of cancer is still there, and having to deal with such a young patient population makes us even more vigilant. Dr. Fichera, you ve moved from the University of Chicago to the University of Washington and the SCCA (Seattle Cancer Care Alliance) to direct the Colorectal Surgical Oncology Program there. Why such a devotion to teaching the specialists of tomorrow? I remember growing up and going through medical school-- two or three key figures in my training, and as I remain grateful to them I want to pass on what I have learned from those masters, not just of surgery but of medicine and gastroenterology. I want to pass the knowledge I received from them to the next generation, and not only pass the knowledge we have accumulated and we have achieved but also push them and stimulate them to grow further, as I m trying to do myself. Dr. Fichera, you mentioned earlier how the knowledge is expanding about colon and rectal cancer. It would seem the message then for patients is it is important to get a second opinion to make sure all that knowledge benefits them. It s important for the patient to know what the best options are available out there before embarking in any treatment. The most successful surgery is the first surgery. We often see patients that have surgery elsewhere; they come to us with either complication or cancer recurrence. The second operation, no matter who does it, no matter how skilled, experienced and trained he or she is, is not as easy, and often it s not as effective as the very first surgical operation. Dr. Alessandro Fichera, thank you so much for coming to the University of Washington and the Seattle Cancer Care Alliance, and bringing your expertise to patients, family members, and your devotion to teaching. 4
Thank you very much for asking me to share my feeling and thoughts with you. Thank you. This is what we do on Patient Power, is connect you with leading experts like Dr. Alessandro Fichera. Thank you for joining us. I m Andrew Schorr. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of Seattle Cancer Care Alliance, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. 5