Join experts from Stony Brook Cancer Center for an informative conversation about colon and rectal cancer screening, diagnosis and advanced treatment options.
In this episode, experts will discuss the importance of screening, walk you through what to expect during a colonoscopy, and discuss screening options other than colonoscopy. You’ll also hear about the latest advancements in surgical, medical and radiation oncology, as well as in colonoscopy.
The Experts
What You’ll Hear in This Episode
- 00:00 Opening and Introductions
- 1:33 What is a colonoscopy?
- 2:28 Why are people scared of getting a colonoscopy?
- 3:53 Why should people get a colonoscopy at the age of 45?
- 6:10 Screening options other than colonoscopy
- 9:08 FAST TRACK Screening Colonoscopy Program at Stony Brook Medicine
- 11:35 What happens when a patient is diagnosed with colorectal cancer?
- 15:42 Colon cancer v. rectal cancer treatment
- 17:17 Advancements in colorectal cancer treatment options (surgical, medical and radiation oncology)
- 23:09 The role of immunotherapy in rectal cancer treatment
- 26:36 Advancements in colonoscopy
- 29:40 Closing Remarks
Full Podcast Transcript
00:00 Opening and Introductions
Announcer
Welcome to HEALTH Yeah!, where experts from Stony Brook Medicine come together to discuss topics ranging from the complex inner workings of an infectious disease to tips and tricks for staying safe and healthy all year long.
Deborah Nagle, MD
Welcome to HEALTH Yeah! I am Dr. Deborah Nagle. I’m the Chief of Colon and Rectal Surgery at Stony Brook Cancer Center, and I’m here with some of my colleagues from Stony Brook Medicine to discuss colon and rectal cancer screening and treatment options.
In the United States alone, colorectal cancer is the third leading cause of cancer-related deaths in men and the fourth leading cause in women. Colonoscopy is considered the most effective method of screening for colorectal cancer and beginning at age 45, all men and women should be screened, even if they aren’t experiencing any issues.
We’ll dive more into that in just a moment. But first, I’d like to ask my friend and colleague, Dr. Aroniadis, to introduce herself and talk with us about what colonoscopy entails.
Olga Aroniadis, MD, MS
Thank you so much, Dr. Nagel. I’m Olga Aroniadis. I’m the Division Chief of Gastroenterology and Hepatology here at Stony Brook. Thanks for the opportunity to connect with you today.
1:33 What is a Colonoscopy?
So as you asked me, what is a colonoscopy? So a colonoscopy is a procedure. It’s a routine procedure that allows us to directly look into the colon or the large intestine.
We use a thin, flexible camera to look inside the colon or the large intestine, and what we’re looking for, specifically for a colon cancer screening, are polyps or early cancers. So colonoscopy is a very effective colon cancer screening test because not only do we have the opportunity to look at lesions, but we have the opportunity to remove them when they’re there. So polyps can grow into cancers when they stay in the colon for a long period of time, at least some of them can.
So colonoscopy not only provides an ability to make a diagnosis, but also to remove polyps and prevent the development of cancer. And so that’s why it’s so effective.
2:28 Why are People Scared of Getting a Colonoscopy?
Deborah Nagle, MD
So why are people so scared of having a colonoscopy? I mean, I personally see so many patients who have not had a colonoscopy in the recommended timeframe by age 50 or 45.
Olga Aroniadis, MD, MS
Yeah. So there are so many reasons, I think, why patients are scared of a colonoscopy. It is an unknown. It’s a procedure definitely anxiety provoking, and can put patients in a very vulnerable state. And so I’m hoping that today we can share with folks what a colonoscopy entails to dispel some concerns. But it is generally a very simple procedure.
We ask patients to take a bowel prep, and honestly, that is the most unpleasant part. That is the most unpleasant part of a colonoscopy, for sure, but it is a very important part. It’s a critical step, and the colonoscopy prep allows us to see clearly when we’re doing a colonoscopy, so it’s vitally important, though unpleasant.
However, when you come in for a colonoscopy, you meet with an anesthesiologist, you get sedation or anesthesia for the procedure, so patients are very comfortable throughout the procedure. They don’t feel or remember anything truly and so that often surprises patients. When they wake up, they can’t believe they went to sleep and they’re awake already and feeling fine and not remembering exactly what happened. But procedures are usually very safe and easy.
Deborah Nagle, MD
So why should people do it at 50 or now we’re recommending 45, why the shift? Where did that recommendation come from?
3:53 Why Should People Get a Colonoscopy at the Age of 45?
Olga Aroniadis, MD, MS
So there are new guidelines now that recommend colon cancer screening starting at the age of 45. It used to be 50, as you said, but now it’s 45 years old, and the reason for that is that we have recognized that there are more patients who are younger who have developed colon cancer. So there’s an increased risk that we’ve seen over the years in younger patients.
And so coming for a colonoscopy, it really allows young patients the opportunity to be appropriately screened because, as you mentioned, many times there are just no symptoms at all, which also surprises patients. That’s the reason we do these screening tests because patients, most of the time, have no symptoms, even if they have early cancer.
And that’s why that screening test is so important because most of the time, patients will feel just fine, even if they have an early cancer that’s slowly growing. And so we can intervene on that, and we can get patients better. We can treat them earlier. We can remove early lesions endoscopically. And it’s so important that young patients come to us to get screened.
Deborah Nagle, MD
So that’s so awesome because what patients clearly do not understand is that just because they feel fine, something could be brewing, and we can intervene when it’s an early stage, and they could be totally fine with a small procedure, as opposed to having a bigger operation and a more advanced diagnosis.
Olga Aroniadis, MD, MS
Yeah, I think that’s what makes this test so powerful. Absolutely. I think, you know, it’s certainly important if any patients are listening who do have symptoms like rectal bleeding or abdominal pain or iron deficiency, all those things certainly should come to the attention of a provider and undergo this test as well. But in all those asymptomatic patients who are feeling just fine, it’s still important starting at the age of 45.
6:10 Screening Options Other Than Colonoscopy
Deborah Nagle, MD
So Olga, what about those patients I see, you see, just won’t have a colonoscopy. Somebody in their family had a bad experience. Whatever the reason, they just refuse to go forward with a colonoscopy. How can we screen those patients? What can we recommend to them?
Olga Aroniadis, MD, MS
Absolutely, and I’m so glad you brought that up because the best screening test that a patient can have is the one that actually gets done. So there are other screening modalities that you can use for colon cancer screening that are not a colonoscopy and that are not invasive. They include stool-based testing, which can be done in the home, like a cologuard test or a FIT test, where a patient has a kit, they collect a stool sample, they bring it in, and that can give you a positive or negative result.
And then also a CT colonography, which is also minimally invasive. It still requires a bowel prep, but it’s an imaging test. The important thing to know about these tests is when they are abnormal, that triggers the real need for a colonoscopy to look in any way and see what it is we’re dealing with. But as I mentioned, really the most important thing is that patients get screened in whichever method that suits them and is appropriate for them after a discussion with their healthcare provider.
Deborah Nagle, MD
And so you mentioned FIT testing for blood in the bowel, or cologuard. Cologuard, they actually send the kit back, right? They provide a sample and then they mail it in. So with FIT testing, what do they do for that?
Olga Aroniadis, MD, MS
It’s also a stool-based sample that they drop off at the lab. So one’s a mail-in kit and the other one is dropped off at the lab.
Deborah Nagle, MD
Okay. And are the, as we say in medicine, sensitivity and specificity just as good with those tests compared to the colonoscopy.
Olga Aroniadis, MD, MS
So the benefit of colonoscopy, and what makes it so unique, is that we can see polyps, and we can see lesions, even advanced polyps, or detect early cancers that we can directly intervene upon. Direct visualization has a higher likelihood of doing that than a stool based test. So those stool based tests are really good for detecting cancers, but not as good at detecting polyps or aggressive polyps or early lesions, and that’s why colonoscopy oftentimes is the preferred method, but as long as patients get screened, I’m happy.
Deborah Nagle, MD
Right. So I think we can both agree that as long as patients are getting screened, we are okay with any methodology, knowing that they will need to progress to colonoscopy if one of the non-colonoscopy methods turns out to be positive.
9:08 FAST TRACK Screening Colonoscopy Program at Stony Brook Medicine
Olga Aroniadis, MD, MS
That’s correct, yep, absolutely. And one thing I’ll say is that we have a great program at Stony Brook, our FAST TRACK program, which really engages young patients or patients who are healthy and need colon cancer screening. It makes the process really easy for them to undergo a colonoscopy because the patient will get on the phone with our team, they will provide all the instructions that are necessary. The patient doesn’t have to come in for an office visit. They can get everything set up directly through our FAST TRACK program, just with that one phone call, so they can go from that phone call directly to a colonoscopy. It really improves access and ease of scheduling and just helps to avoid delays and really expedite the whole process for our patients.
Deborah Nagle, MD
So I’m 46, I hear that I should have a colonoscopy. I wish I was 46. I feel like I heard that I should have a colonoscopy of 45. I think I’m totally healthy. I can call your office and I can say, I just want to get a screening, and I can be put in the FAST TRACK program without taking time off of work, doing anything else besides doing the bowel prep, and then I can just show up for my screening colonoscopy. Is that right?
Olga Aroniadis, MD, MS
Yeah, that’s correct. So we have a separate phone line for our FAST TRACK program, and patients will talk with a nurse and someone as scheduler as well, and a one-time phone call, and they’ll do all the intake, they’ll get all the patient’s information, obtain background information and medical history, determine the appropriateness of a direct referral colonoscopy.
And once all those things are discussed, and once we determine that a patient is eligible and is appropriate, then we could just schedule them directly for a colonoscopy, and they just show up the day of, after understanding all the instructions with the discussion they’ve had with the nurse.
Deborah Nagle, MD
Thank you, Dr. Aroniadis, for taking the time to discuss colon and rectal cancer screening with us and educating us about the benefits and the risks. Next, we are going to come right back with Drs. Gemmill and Stessin to discuss treatment options for colorectal cancer.
11:35 What Happens When a Patient is Diagnosed With Colorectal Cancer?
Welcome back. I’m now joined by Dr. Gemmill of medical oncology and Dr. Stessin of radiation oncology to talk about what happens when a patient is diagnosed with colorectal cancer.
Doctors, could you just briefly introduce yourselves?
Julie Gemmill, DO, MS
Sure. Hi. I’m Julie Gemmill. I’m a Hematologist Oncologist here at Stony Brook, and I have a sub specialty focus in the treatment of GI cancers.
Alexander Stessin, MD, PhD
All right, I’m Alex Stessin. I’m a radiation oncologist at Stony Brook, also specializing in the treatment of GI cancers. I’m happy to be part of this team.
Deborah Nagle, MD
And we are a team because we are all working together for patients who have recently found out that they have colorectal cancer, which is always a shocking and difficult thing for patients to hear, right?
So let’s talk about what first happens after a patient receives a diagnosis of colorectal cancer. What do we as a team do to evaluate the patient and understand what their staging is and what are the next best choices?
Julie Gemmill, DO, MS
Right, so, you know, Deb, as you mentioned, I think that a new cancer diagnosis is very stressful to patients, and they’re hearing things, a lot of things, for the first time, and that can be overwhelming. So usually what I’ll recommend patients do on the first visit, they come with a family member or even a close friend who can serve as a second set of ears to help kind of absorb all the new information that they’re receiving.
Deborah Nagle, MD
So crucial for any visit, right?
Julie Gemmill, DO, MS
I guess in terms of a management plan, one of the important things is diagnosis. So we want to have biopsy confirmation of cancer. The second most important thing is staging. And I think a lot of people don’t realize how important this is, but ultimately it serves to guide our management plan.
And so from our standpoint, in medical oncology, we order scans to determine the stage of the disease, and usually what that entails is a CAT scan of the chest, abdomen and pelvis to see if the cancer has spread to any other organs, like the liver, the lungs or the abdominal cavity.
Alexander Stessin, MD, PhD
And in radiation oncology, we rely on these scans to also guide our therapy. And, you know, show us the anatomy where the disease is, where the disease might be, and this is what we make our plans based on.
Deborah Nagle, MD
But what are there different scans that you would order for radiation oncology?
Alexander Stessin, MD, PhD
When patients come to us, first, we meet them in consultation, obviously, and explain to them the treatment and so forth, and then the next visit that they typically have with us is a special kind of scan called CT simulation, which has done the exact same position that they will be during treatment. And then based on that scan, we make the treatment plan, and sometimes we overlay it with some of the diagnostic imaging that they’ve gotten before, including PET scans and MRIs. And this helps us to really delineate where the disease is and where we want to focus our radiation treatment on.
Deborah Nagle, MD
So if we decide the patient is appropriate for radiation therapy, then you’re doing dedicated scans for that purpose. Okay, so, but back to the initial staging. We’re doing a CAT scan from basically the neck to the thighs, and we’re doing blood work, right? Are we doing anything else? Those are, those are pretty much our basics, correct?
Julie Gemmill, DO, MS
Yeah, those are pretty much the basics. I’ll do a whole panel of blood work to make sure that patients have normal kidney function, liver function and normal blood counts, because one thing that chemotherapy does is it suppresses the marrow function, and it can cause what we call cytopenias, where the blood cells become very low.
So we’ll generally run a complete blood panel. We’ll also do a serum tumor marker called a CEA level, and this will be monitored through the course of therapy and helps us gauge treatment response, and I’ll look for a number of other things that I think we’re going to go into a little bit later.
15:42 Colon Cancer v. Rectal Cancer Treatment
Deborah Nagle, MD
Okay, so colon cancer and rectal cancer are in our world, kind of two different beasts, right?
For us as a group, medical oncology, radiation oncology, surgical oncology, so all of our specialties may or may not work in each of these diseases.
For colon cancer, most of it is surgical oncology and medical oncology. For rectal cancer, it’s radiation oncology, surgical and medical. So let’s talk about where most patients with colon cancer start out. I think pretty much we agree that it is surgery for most patients for colon cancer, if they’re appropriate.
Are you in agreement?
Julie Gemmill, DO, MS
Yeah. So getting back to the staging that we talked about earlier, if the CAT scans are negative for any disease or cancer that’s spread outside the colon, then the first step would be surgical resection, and that’s where the colorectal service really takes the forefront.
After surgery, patients will usually come back to see me in medical oncology, and at that point, we’ll determine the need for adjuvant or after surgical chemotherapy treatment to reduce the risk that the cancer comes back, right? And that’s based on the surgical pathology report that you know that the pathologist generates.
17:17 Advancements in Colorectal Cancer Treatment Options (Surgical, Medical and Radiation Oncology)
Deborah Nagle, MD
And so the great thing, and so one of the things I want to highlight for all of us is, what are the changes that have occurred in each of our specialties in terms of management of colorectal cancer.
For us in surgical oncology, minimally invasive surgery is a huge, huge change in benefit for patients. So most patients are able to have minimally invasive surgery, which really means incisions the size of my thumbnail. It’s not one, it’s at least four, possibly more. But instead of a big incision in the middle of the abdomen, patients can have tiny incisions that really increase their or decrease their recovery time and decrease their risk of infection and decrease their risk of an anastomotic leak.
So this is huge for most patients. I will actually say that your average patient who doesn’t have a physically demanding job like crane operator or school teacher will be back at work part time within two weeks after minimally invasive surgery, if that’s appropriate. And then depending on what else we think is needed next. So that’s a really big change for us in surgical oncology.
And so I know that there are changes in medical oncology as well, with personalized study of the tumor and testing.
Julie Gemmill, DO, MS
Yeah, that’s right. We really are in the age of precision medicine and individualized care, and a large component of that is molecular testing. For every patient that I see with advanced colon cancer, I’m sending a special panel that consists of a piece of the tumor tissue itself that’s sent out to a specialized lab. And at that lab, they genetically sequence the tumor tissue and create a unique profile, looking for genetic alterations. Sometimes we call these alterations driver mutations, and if we find a mutation that we can target, we can utilize therapy that we know will be beneficial in that type of cancer.
Alexander Stessin, MD, PhD
Okay, yeah, so for radiation oncology, there are a lot of changes that have happened over the past several decades. I would say that you know, going back to what you said earlier, one of the biggest differences in terms of treatment paradigm for colon and rectal cancer is that radiation plays a role in the treatment of rectal cancer much more so than it does for colon cancer, right?
The reason for that is location, right? So below the peritoneal reflection, there’s much more room to radiate and do so effectively while having minimal toxicity.
Deborah Nagle, MD
Here’s how I think about it, the pelvis is a funnel. Take a traffic cone, turn it upside down. The bottom is the bottom of the pelvis. The upper limit is the top of the pelvis. And then you put a rectum in there. As soon as that tumor grows outward, it is butting up against the walls of the pelvis and the bone, and that’s why I need you, because once those tumors start to grow outward, I need you to shrink them down before I can actually take them out with surgery.
Alexander Stessin, MD, PhD
That’s right. That’s right. But going back to colon cancer, you know, traditionally, radiation hasn’t played much of a role in treatment of colon cancer, but that’s actually changed, and one of the biggest advances in our field has been stereotactic body radiation therapy, or SBRT. And now we use that quite commonly in situations where the colon cancer has traveled outside the abdomen. Sometimes it may lodge itself in the lungs or other parts of the body, and in these situations, there is now a very effective and safe way to treat it, which is with this very precise pinpoint radiation. And the patient has to come only for four or five treatments. Typically has no side effects, except for maybe some mild fatigue, and it can be very effective at eliminating these spots that the cancers traveled to.
So that’s for colon cancer. And I guess we can talk about rectal cancer as well, because there have been some exciting changes in terms of the way we treat it, I think, from all of our standpoints, including radiation, right?
Deborah Nagle, MD
Yes, I think that absolutely. So in the US, we’ve had a big migration in the last five years. Would you say is appropriate?
It was, of course, described elsewhere, you know, outside the US before that, but now there’s widespread adoption of what we would call total neoadjuvant therapy, where we lead with chemotherapy, then give radiation, if appropriate, and then do surgery. And it used to be that we would give radiation and chemo first, then do surgery, and then give the real big chemo later, right?
And so the whole paradigm is flipped. But the beauty of it is that up to 40 percent of patients we now know will respond to the chemotherapy and radiation therapy and don’t need surgery. So it’s really upended the way we think about and manage rectal cancer in the last three years, I would say.
Alexander Stessin, MD, PhD
Yeah, yeah, this has been a true game changer, I think, right? And you know, when you go back to the clinical trials that define how we treat rectal cancer, you know, back in 2005, they looked at the rates of what we call a complete response, where a patient doesn’t need surgery after getting radiation and chemo first. And it was, you know, 8 percent, 8 to 10. And now we’re up to 40. This is huge.
Deborah Nagle, MD
It’s remarkable, right? It’s great to be alive during times of medical advancement.
23:09 The Role of Immunotherapy in Rectal Cancer Treatment
Julie Gemmill, DO, MS
And I think we’d be remiss if we didn’t talk about the role of immunotherapy in rectal cancer as well. Several years ago, there was a trial looking at immune checkpoint inhibitors in patients who are deficient mismatch repair early stage rectal cancer, and the results were astounding. They essentially saw complete clinical responses in all patients treated with a PD-1 inhibitor called Dostarlimab, which really is a game changer when you don’t have any evidence of disease, either by endoscopic evaluation (colonoscopy), physical exam or imaging.
Deborah Nagle, MD
But what happened when that news came out, everybody was calling your office saying, I want that drug. I want that drug. So we really have to be clear about who are the patients who actually qualify for that drug, right?
Julie Gemmill, DO, MS
Right. So one of the things that I look for in all patients with colorectal cancers are their mismatch repair profile. So mismatch repair proteins are really a DNA repair system, and they repair errors that occur during DNA replication. And when these mismatch repair proteins are deficient, errors in DNA replication accumulate, and this leads to genomic instability, and that’s a big driver for cancer occurrence.
So unfortunately, only a subset of patients will be of this profile with a deficient mismatch repair. We also call that microsatellite in stable or MSI high. So they’re synonymous with one another. Unfortunately, not all patients will qualify for these newer immunotherapies, specifically immune checkpoint inhibitors.
Deborah Nagle, MD
So let’s be real, Julie, most people who are listening to this don’t talk gene therapy. So really, what we’re talking about is you’re testing the tumor to see if the genes are torqued or tweaked in a way that they would respond to this one drug, this one kind of therapy. And correct me if I’m wrong, but the reality is about 10 percent or less patients with colorectal cancer will actually have this gene tweak that would allow them to have that medication. Is that right?
Julie Gemmill, DO, MS
Correct. It’s around 15 percent of patients with colorectal cancer, and the numbers get lower with more advanced stage disease. However, even if a patient isn’t deficient in mismatch repair proteins, if they’re not MSI high, we could identify another driver mutation, like BRAF, KRAS or even HER2 that have effective therapies for treatment.
26:36 Advancements in Colonoscopy
Deborah Nagle, MD
Which is why we do all kinds of genetic testing on every tumor to help guide medical therapy, radiation therapy, and not so much for surgery, but definitely for medical and radiation. It can tell us what’s the best treatment pathway to put a patient on, right? And again, to further personalize their treatment plan.
So one area that’s really interesting to me as a surgeon is that with endoscopic or colonoscopy advancements, more and more the GI doctors are identifying polyps at an early stage, taking them out and then finding cancer. And then they send them to us, saying, Oh, the patient has cancer. What do we do now?
And so we are looking at a whole new algorithm about how we address those patients in terms of, do they need additional treatment with medical oncology or radiation oncology. What are you guys seeing?
Julie Gemmill, DO, MS
Yeah, I’m seeing the same things, and usually when patients see me in the office, I’m looking through the staging imaging. I’m looking through the surgical pathology reports to determine if there are high risk features that warrant adjuvant chemotherapy. Some of the features I look for, for instance, and you know this very well, tumor size, whether there are lymph nodes involved with the cancer and then other details, like surgical margins, the invasion of lymphatics or vascular spaces. Even how cells look under the microscope, whether they are normal appearing, or if they look a little bit more abnormal, those are all features that are historically known to be high risk for cancer recurrence, and it may incentivize me to offer chemotherapy to reduce the risk of recurrence.
Alexander Stessin, MD, PhD
Yeah, very much the same line of thinking with radiation. Obviously, radiation plays more of a role in treatment of kind of locally advanced rectal cancers, the ones that have traveled to lymph nodes that have grown through the rectal wall. But you know, I would say that, you know, 10-15 years ago, this was all done in a kind of a standard way, with anticipation of a bigger surgery. Now, you know, I’m thinking about it a little bit differently, and, you know, sometimes I give a little bit more radiation dose than we used to, in hope that we can get a complete response and they can avoid a bigger surgery, and the chemo and the radiation would really do the job and there’s nothing left behind.
Deborah Nagle, MD
But also, Alex, we have patients that we’ve shared that have had endoscopic or colonoscopic resection of a distal, meaning mid or distal rectal polyp shows up, turns out to be cancer. There’s concern, and then we say, Oh, we don’t want to do surgery and take out your rectum and rebuild everything. But because of these unfavorable features, we’d like you to have radiation or chemo.
Alexander Stessin, MD, PhD
Yeah, because we know that radiation and chemo and combination work very well for what we call microscopic disease, right, disease that we can’t see on imaging or even on the scope, but we know that there may be some cells left behind, and the radiation chemo will take care of them.
Deborah Nagle, MD
Which all points to the fact that we are continually customizing and personalizing treatment for every single patient.
29:40 Closing Remarks
So that’s all the time we have today. Thank you both for your expertise and your time, and thank you to our viewers and listeners. If you found this conversation interesting, don’t forget to like and subscribe for more informative health related content.
Announcer
Stony Brook Medicine is Long Island’s premier academic medical center. We transform lives through scientific discovery, education and care, and we bring together innovative research, advanced education and extraordinary health care expertise to set the standard for how healthy communities thrive. For more information, visit stonybrookmedicine.edu or follow us on social media.
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