GLMS Foundation Senior Physician Speaker Series Curated and hosted by Sam Yared, MD
Topic: Latest Advances that Improve Outcomes in Colorectal Cancer Guest Speaker / Author: SANDY KAVALUKAS, MD, FACS, FASCRS
This discussion highlights the overall importance of colorectal cancer( CRC) care specifically in Louisville and in Kentucky. I provide a brief overview of the previous standards for colorectal cancer treatment and examine new treatment regimens that have led to better outcomes. Lastly, the importance of early onset colon cancer and overall considerations in CRC treatment are discussed.
Although the overall trend in colorectal cancer incidence has been decreasing across all age groups, primarily due to better access to screening colonoscopy, the early onset colorectal cancer incidence has skyrocketed. Kentucky, though achieving the expected 70 % rate of screening, still has the highest incidence in the U. S. What is more alarming in Louisville is that there are clusters of cancer, particularly in the West End, that that have even higher incidence rates than the rest of the state.
Colon cancer is discussed first, as it is one of the more straightforward cancers to take care of. Currently, after it is identified and properly staged, if it is not metastatic, typically surgery is the first step, and adjuvant chemotherapy if indicated is the next step. Not much has changed in those guidelines, though we will discuss the role of metastatic disease and how treatments for that have improved. If we look at survival, we can see that the overall survival came up from 51 % to 64 % in the previous 20 years simply by adding 5-FU
to the chemotherapy regimen.
Rectal cancer, however, is a much more different beast. Due to its location in the deep pelvis, neoadjuvant radiation has typically been the standard for the past 20 years, and we review the data from the Swedish and Dutch colorectal trials to support this. Although some of the early staging was formerly done via ultrasound, this has fallen out of favor due to important tumor aspects including surgical margin clearance( whether cancer cells absent or present), the involvement of internal iliac or obturator nodes and the tumor’ s height from the anal verge. All of these are key considerations in rectal cancer care and help to target radiation therapy. Additionally, if the clinical course includes a period of“ watching and waiting,” we need very reproducible and translatable images with which to compare treatment response.
The biggest change in rectal cancer care has been the widespread adoption of total neoadjuvant therapy( TNT). There are many reasons to support this regimen, most of it being that only 40 to 60 % patients were able to complete all the recommended chemotherapy when it came after surgery and the surgical complications with these difficult surgeries often led to delays to chemotherapy. This data has been so compelling that it is now adopted by the National Comprehensive Cancer Network( NCCN) as the preferred method of treating rectal cancer.
An unexpected finding after we started to doing TNT, is that there was a relatively large proportion of patients( 30-40 %) who achieved a complete clinical full response after the neoadjuvant
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