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Q: Welcome to Understanding Cancer. Today we’re visiting with Dr. Bendell from the Sarah Cannon Research Institute in Nashville, Tennessee. Welcome to the show.

A: Thank you so much.

Q: What we’d like to talk about today is colon cancer. And colon cancer is, frankly, just as common as breast cancer, but it doesn’t seem to get anywhere near the attention.

A: True. Very, very true. I think maybe it’s hard for people to talk about colons – [laughs] – and the tests that go with them.

Q: That’s actually a good place for us to start. How is colon cancer typically diagnosed?

A: Typically we see people get diagnosed with colon cancer after colonoscopies or screening, and that’s when we hope to get people diagnosed with colon cancer, ‘cause usually when people are diagnosed on screening, the colon cancer is found to be at a lot earlier stage where we can cure the colon cancer. And screening is a little bit controversial in the United States, but pretty much people will suggest that having a screening sigmoidoscopy every three to five years or having a colonoscopy every five to ten years would be a good enough screening tool to be able to catch polyps while they’re still in the polyp stage and have not become overt colon cancers yet.

Q: And when do the organizations recommend that screening begin?

A: So for the average person, average risk, you’d be looking at about 50 years old to start your screening. Now, if you’ve had what they call a first degree relative – a mother, a father, a brother, a sister or even a child with colon cancer – they would suggest that you get tested about ten years earlier than the age of diagnosis of that family member that had colon cancer. And in fact sometimes people will even go as far as to suggest that if you have grandparents that had colon cancer or there’s some sort of hint of cancer within the family, to get tested a little bit sooner.

Q: So most patients that are diagnosed with colon cancer have the disease detected on a screening colonoscopy or a sigmoidoscopy?

A: That’s what we hope for. Occasionally we do see patients that come in to us when they’ve had a change in their bowel movements or they’ve had some sort of symptoms from their colon cancer rather than being screened. Oftentimes when you have symptoms from your colon cancer, that can suggest that we catch the colon cancer at a little bit more advanced stage, so we prefer to see people come in with diagnosis at screening.

But if they don’t, sometimes people can notice that their stools have become thin, stools have become loose, or they’ve noticed some blood or darkness in their stools, they’ve had weight loss or fatigue for some reason or another, and those are the most common other symptoms that you might see – that would bring people in to the doctor to be diagnosed with colon cancer.

Q: And the actual diagnosis occurs because a biopsy was performed during the colonoscopy or the sigmoidoscopy?

A: Exactly. The way to diagnose somebody with colon cancer is to actually get that piece of tissue and to look at the tissue to confirm that it is colon cancer. We never want to try to assume that somebody has colon cancer until we’ve actually seen it under the microscope. Occasionally there are people that have some other type of cancer that’s been sitting there, like what we call a neuroendocrine type cancer, which is very different than colon cancer, or even sometimes it’s not cancer at all. So the most important part is to get that tissue checked.

Q: So once you have a tissue confirmed diagnosis of colon cancer, what doctor is responsible for beginning the treatment process?

A: Well, usually, as an oncologist, I’d probably say the oncologist is the best person to go to first. Sometimes you will see that patients will have a colonoscopy that’s done by a gastroenterologist, and that gastroenterologist, if they find the colon cancer, will then send the patient to a surgeon. We prefer that patients go to surgeons who have a lot of experience with colon cancer and removing colon cancer, just because we’ve seen that patients who go and have surgeries done by people who do a lot of these different types of cancer operations will have better outcomes than people who go to a surgeon that might do just a couple of them a year. So they might come through the surgeon first, and then the surgeon will then send that patient to the medical oncologist once the surgery is performed.

Q: Okay, so when I saw patients, that was kind of how the workflow went.

A: Yeah.

Q: It was typically – the oncologist was typically the second person—

A: Yeah.

Q: –that was involved in the process after the surgical removal of the cancer had actually taken place. Today, I mean, are more and more people getting to a medical oncologist first?

A: It’s still a little bit mixed, but usually they do come from the surgeon first. One reason, as a medical oncologist, that I might like to see the patient before the surgeon is to make sure that the appropriate, what we call staging tests, are done. Now, most surgeons do these. But what these staging tests are are CAT scans of the belly to make sure that there’s no sign of spread of the disease to other organs such as the liver or lymph nodes. And we would also recommend patients get either a CAT scan of the chest or a chest X-ray to make sure there’s been no spread to the lungs.

The other thing that we do like to get is a blood test prior to them having the original cancer removed, which is a blood test called a CEA. And for some patients, when that CEA is high, it suggests to us that the colon cancer is active, and when the CEA goes down to low, that tells us that the colon cancer is dormant. And it’s good to be able to follow that level and know who we can follow that level in. So as a medical oncologist, we do like to have these tests done, and sometimes the surgeons do them, sometimes they don’t, so we do like to be involved. But mostly the surgeons will sort of take the handle right off the bat.

Q: But if you’re a patient and you’ve been diagnosed with colon cancer, it’s not unreasonable to get a medical oncologist involved early in the process?

A: Absolutely not, and the medical oncologist can be very helpful to you by suggesting these things and actually working with the surgeon. The medical oncologist might also be able to suggest a good surgeon who they’ve worked with a lot, especially since they deal mostly with cancer patients, might be able to suggest to you a very good person to take out that colon cancer.

Q: And what is going to be the primary treatment for colon cancer?

A: So the best treatment for colon cancer is surgery. Surgeons always joke “to cut is to cure,” which is very true. If we are able to remove the colon cancer, and it’s just in the colon, the primary treatment is to get that cancer out and to find out how far that cancer has spread. Some patients might be done after the surgery and just be followed up with regular CAT scans and blood tests and colonoscopies, and then some patients might need chemotherapy after their surgery is performed to increase their chance that the surgery has caused a cure.

Q: When the surgery is completed and the staging workup is completed, you can actually assign a level that the cancer has spread to the patient called a stage?

A: Exactly.

Q: Okay. And the earlier stage cancers are treated primarily with surgery, but later stage cancers may have other therapies involved?

A: That’s right. So what we call Stage I cancers or Stage II cancers, which are confined only to the colon and the colon wall, are generally treated with surgery only. There is some controversy as to what we call Stage II cancers where there has been – it’s confined to the colon only and has not gone to any local lymph nodes, but some patients will be – will have treatment recommended to them, and we can discuss that, who those patients are.

And then there’s patients with Stage III cancer who have their cancer confined to both the colon and the local lymph nodes, and then patients who have Stage IV cancer who have colon cancer that’s spread to other organs. Cure is available to all of these patients, depending on how far the cancer has gotten.

So, for instance, with patients who have Stage III cancer, where it’s gone to local lymph nodes, they can have their colon cancer taken out, and we would typically recommend about six months of chemotherapy after that colon cancer is taken out to improve the chances of having that surgery be a cure. For patients with Stage IV cancer, where it’s spread to a different organ such as the liver or the lung or lymph nodes that are farther away than just the local colon lymph nodes, we can even cure some of these patients now with some of the more advanced chemotherapies and surgeries that we have.

So it’s always important to have the surgeon and the medical oncologist take a look at the pathology and at the CAT scans and the staging workup to make sure that you’re on the right treatment path.

Q: So the primary local treatment is surgery, but because we know that some of these cells have already left the colon, we’re going to look at additional therapies to reduce the patient’s chance of experiencing a recurrence?

A: That’s right.

Q: So the primary treatment is going to be surgery, and you’ve already mentioned that chemotherapy is used in the Stage III patients.

A: Mm-hmm.

Q: But I see you hedging a little bit on the Stage II patients.

A: Yes.

Q: Is chemotherapy standard for Stage II or is it a little controversial?

A: So chemotherapy for Stage II patients is very controversial. There are some patients with Stage II disease where it’s not controversial, and there’s almost a universal recommendation to give chemotherapy in the Stage II setting, and these are patients who come in and they have something called a T4 tumor, where the tumor has spread outside of the colon wall, so those patients should be getting chemotherapy.

For patients who had what we call inadequate lymph node sampling, if there are less than 12 lymph nodes that were looked at in the pathology specimen, one can suggest that they hadn’t had enough lymph nodes looked at to say whether or not they were Stage II or Stage III, so people will recommend chemotherapy based on that.

For patients who have tumors that are called poorly differentiated tumors, when the pathologist looks at the tumor under the microscope, the less and less the cancer cells look like real colon cells, they call them less and less differentiated. So if they’re poorly differentiated, one would suggest that you should probably receive chemotherapy if you’re Stage II, just because those patients – or those tumors tend to be a little bit more aggressive.

Q: Is chemotherapy ever recommended for Stage I patients?

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A: No. Chemotherapy should not be given routinely for Stage I patients.

Q: So you’re seeing a patient that’s been recently referred to you that you’re going to recommend chemotherapy to.

A: Yeah.

Q: How do you describe chemotherapy and the potential benefits of receiving it?

A: Sure. I find that a lot of patients, when they come in to see me for the first time, are very nervous about chemotherapy because they’ve had family members that have been treated in the past with very aggressive chemotherapies, or they’ve watched a lot of television or movies that show people getting very sick with chemotherapy.

And what I do try to reassure them about is chemotherapy these days is a lot different than it used to be, and people work with chemotherapy. I tell them that I’ve had patients who have done construction on this type of chemotherapy, and have been able to carry on normal lives with their chemotherapy.

Q: Does radiation ever play a role in the management of colon cancer?

A: Sometimes it does. It plays a role mostly in the management of rectal cancer, which is a very low colon cancer, and we tend to want to give radiation therapy in combination with chemotherapy to those patients who have rectal cancer; that’s the standard of care. Sometimes you’ll see radiation therapy for patients with colon cancer if their tumors in the colon had been what we call adherent to different parts of the pelvis.

Sometimes we’ll give radiation along with the adjuvant chemotherapy for those patients, though it is somewhat controversial as well. And sometimes if patients have had disease that has spread, then we might consider radiation if there’s one spot in particular that’s causing a problem that we want to just hit with a little dose of radiation therapy.

The chemotherapy is generally a treatment called FOLFOX, which involves three different drugs. One is called 5-FU, or 5-Fluorouracil, which has been around since the 1960s for colon cancer; a drug called Leucovorin, which is a vitamin that helps the 5-FU work better; and a drug called Oxaliplatin, which is another type of chemotherapy. And these are given every – in general every two weeks for a total of six months of therapy. Patients tolerate this regimen very well.

And I do tell my patients if they don’t feel well on this chemotherapy regimen, they need to let me know, because there’s often something I can do about that, either by way of supportive care medications or changing the doses or frequency of the chemotherapy to help them tolerate it a lot better.

Q: What kind of side effects might a patient experience with FOLFOX?

A: So with FOLFOX chemotherapy, one of the more common side effects is diarrhea. Less than 1% of patients will have a very, very serious diarrhea which is a life threatening diarrhea and would happen right away, and we would know it. And I tell the patients that if they start to notice that they have diarrhea, to take Imodium. And I recommend that they take two Imodium every two hours, and if they aren’t able to control their diarrhea, to call into the office. The office knows and the doctor knows to stop their chemotherapy if it’s still running and to try to get them in to help support them.

Some people may have some mild nausea or vomiting, but we have wonderful medicines now that can curb that and have people tolerate it very well. And the other thing we see a lot of is what we call numbness or tingling in the fingers or toes, and this happens because of the Oxaliplatin. And what I tell patients who do is watch that, and if it starts to be something that lasts and lasts and lasts, that’s a sign for me to either stop the Oxaliplatin or decrease the dose so they don’t get any kind of permanent numbness or tingling in their fingers or toes.

Q: If people do develop the neuropathy or the tingling and numbness, does it tend to resolve or is it permanent?

A: So it tends to resolve, but it can resolve over years. In the studies that were done originally with the FOLFOX regimen, it can take sometimes up to three years to have that numbness or tingling resolve, and there is a very small percentage of patients where it’s permanent, so we tend to be very sensitive when people start to get this neuropathy or numbness and tingling to try to get on top of it very quickly so you don’t run the risk of having a permanent problem with neuropathy.

Q: Now, when you’re discussing chemotherapy with an early stage patient, how do you quantify the potential benefits of receiving chemotherapy?

A: Yeah. Well, there are computer programs that can calculate out specifically for the patient what their risk of having their cancer recur is. But what I do is I give them almost a numeric education on the risk of recurrence. So what I say is the very average Stage III cancer patient has about a 50% chance of having their cancer come back. What adjuvant chemotherapy will do, or the six months of FOLFOX chemotherapy will do, is decrease that risk by about 25%, so it’s going to take them from a risk of 50% recurrence to about 37.5% recurrence.

And that gives people a little bit of an understanding of how much benefit this therapy can give them. And I can also tell them that we’ve seen in clinical trials that more people survive if they have this adjuvant therapy, because of this decreased risk of recurrence. So even though it’s about a 25% drop in the risk of recurrence, that’s still pretty significant and worth the six months of chemotherapy.

Q: Now, some patients might say, if I don’t get the chemotherapy, why can’t I just get it if my cancer comes back?

A: Well, oftentimes, even though we can cure some patients who have what we call Stage IV disease, which is where the cancer has come back and moved into different organs, we aren’t as good at curing it when it’s in Stage IV as we are in Stage III. So it depends where it comes back and how it comes back. And so what we just don’t want to do is let that cancer loose and give it a chance to grow, because once we’ve done that, we don’t – it’s very unpredictable as to where it’s going to recur and if we’re going to be able to cure somebody when it does recur.

Q: Do clinical trials play a role in the management of, again, early stage disease, not late stage disease?

A: I think clinical trials in any stage disease are the most important things that we can do. Clinical trials give patients the opportunity to have new agents that are being studied for the treatment, and all of the agents that we have now for the treatment of colon cancer were once in clinical trial, and the patients who received those in clinical trial obviously benefited from them. And they’re going to help us not only help the patients that are on the trial, but help future patients with colon cancer.

So I do believe that clinical trials are a mainstay in the treatment, and if there is a clinical trial that’s available to you as a patient, I usually highly suggest that people try those clinical trials, because of the potential benefits that it has for either the patient themselves or for future patients with colon cancer.

Q: So in summing up the management of early stage disease, it’s curable.

A: Yes.

Q: Chemotherapy reduces the risk of recurrence and prolongs survival.

A: Absolutely.

Q: And clinical trials do play a major role in patients’ treatment decision-making.

A: Yes. That’s exactly what we want to say to people, is we can cure them, and take that chemotherapy to increase that hope for cure, and then try those clinical trials to maybe increase that hope for cure even more.

Q: Most colon cancer patients are diagnosed with early stage cancer, although some actually do present with advanced disease. And some patients are going to recur from their original diagnosis of colon cancer, and together we call those patients metastatic.

A: Yeah.

Q: Can you explain to our viewers what it means to have metastatic colon cancer?

A: What it means to have metastatic colon cancer is that the colon cancer has spread outside of the area of the colon. It can spread to usually the liver first. Sometimes it spreads to the lungs and sometimes it spreads to local lymph nodes. Very, very, very rarely we can sometimes see it spread to bone or brain, but those are very rare cases. But what it tells is that it’s just gone outside of the area of the colon.

Q: So when you see a new patient referred to you with metastatic colon cancer, what do you tell them?

A: I tell them, first of all, don’t lose hope. What I try to do initially is get a sense of where their metastatic disease is, because there’s some patients with metastatic disease that we can still cure of their metastatic colon cancer, and it depends. If the disease is in the liver only and it’s not all over the liver, but maybe in specific places within the liver, or if it’s within the liver and maybe one spot in the lung, sometimes these patients can be cured with surgical resection of their metastatic disease.

And sometimes we’ll give chemotherapy before sending them to surgery, sometimes we’ll give it after sending them to surgery. So that’s the first thing that I want to check on all of my patients, is to see are they patients that could possibly be cured of their metastatic disease. If they are, usually I will consult with a surgeon who will help me make that decision as to whether or not a surgical cure is possible for those patients.

For patients who are not surgical cure candidates in the metastatic setting, I tell them that our goal is to help them live as well as they can for as long as they can. And what we want to do is combine increasing their survival with chemotherapy treatments with giving them chemotherapy they can tolerate and that they can live every day with and that they don’t feel poorly from.

So a lot of patients will come in very scared that they’re going to get some sort of horrific treatment that’s going to make them feel bad. And what I try to do is reassure them that no matter what, we are going to help them with the symptoms, and we’re going to help them with the symptoms of their disease as well as the symptoms of their treatment, and make it so that they have a good quality of life.

Q: In summing up, is there anything in particular you’d like to tell cancer patients with metastatic colon cancer that they should really think about when they’re diagnosed?

A: Don’t give up hope, never suffer in silence. Always tell your doctor if something is going on, ‘cause there’s oftentimes something people can do about it. And try clinical trials, because there’s so many good trials that are out there that are going to be the way that we find the cure to treating metastatic colon cancer.

Q: Well, it sounds like very good advice, and I really want to thank you for joining us today.

A: Thank you.

Q: And I do hope you’ll come back and visit with us again sometime.

A: Thank you so much.