This article originally appeared in Pathways, a magazine published for physicians and the community by UMass Memorial Medical Center.
A fundamental advantage of tertiary care centers is the access they provide to a significant depth and breadth of specialized medical and surgical resources. When it comes to diagnosing and treating colon and rectal cancer, UMass Memorial Medical Center offers one of the most advanced and comprehensive initiatives in the region. At the heart of this initiative is a multidisciplinary gastrointestinal tumor clinic comprising medical, radiation and surgical oncologists, colorectal surgeons, and gastroenterologists. Additionally, genetic evaluations are conducted with high-risk patients and their families to identify possible genetic mutations that may require further interventions.
"We have made it our business to be on top of every facet of modern treatment," said Giles Whalen, MD, chief of surgical oncology. "For all presentations of colon cancer, from relatively small, primary tumors to metastatic disease, we can employ all treatment modalities to take care of patients appropriately." Further, because UMass Memorial is a leading research center, patients also have access to novel treatments through enrollment in clinical trials.
"As with most things in medicine, there are many treatment option available for patients with colon and rectal cancer," explained UMass Memorial colorectal surgeon Justin Maykel, MD. "With our weekly GI tumor board conferences, surgeons, oncologists, radiologists, gastroenterologists and pathologists get together to discuss unique cases, where we can take advantage of this wide range of expertise and different perspectives to determine the best course of treatment for our patients. It facilitates the whole process."
"The patient can be evaluated in a seamless fashion by all the necessary experts who will be part of his or her care," noted T.J. FitzGerald, MD, chair of radiation oncology. "The doctors collaborate on a care plan in a timely fashion, scheduling tests and procedures, and expediting patient management."
Colon and rectal cancer patients need a lot of coordinated care. The right timing is critical, since there is a limited window of opportunity in which treatment will be most effective.
"At UMass Memorial, we provide cutting-edge staging of colon and rectal cancer through endoscopic ultrasound," said Wahid Wassef, MD, director of endoscopy. "This is an endoscopic test which allows us to see the tumor and its extent much better than any imaging modality currently available." UMass Memorial is the only facility in Central Massachusetts to provide this technology.
The therapeutic options available at UMass Memorial are among the most advanced in the region. On the surgical front, results of a seven-year international study published in the New England Journal of Medicine demonstrated that, when performed by experienced surgeons, minimally invasive laparoscopic surgery is a safe and effective alternative to traditional open surgery in most patients with cancer that is confined to the colon.
"Our surgical team trained in an era when the laparoscopic approach is the standard of care," added Dr. Maykel. "This extra training delivers a clear benefit to patients," he said, referring to the study findings that showed shorter hospitalizations and less use of IV and oral pain medications after surgery in the laparoscopic group. "It is amazing to see these patients after surgery, and how much faster they get back to their daily activities."
Medical oncology also offers leading-edge therapies. There are more effective chemotherapies available today, including new targeted therapies for advanced disease. Oxaliplatin, a newer drug used in adjuvant chemotherapy, has shown to prolong disease-free survival in patients with resected stage II and III colon cancers.
In more advanced cases, Avastin® (bevacizumab) is a monoclonal antibody that attacks the endothelial growth factor. Another new targeted treatment, Erbitux® (cetuximab), works against the epidermal growth factor receptor. Used alone or in combination with chemotherapy, it has been shown to help patients with refractory advanced colon cancer.
The survival rate for advanced colon cancer used to be less than one year. With these new agents and chemotherapy, it is not uncommon to see patients surviving two to two-and-a-half years and beyond.
|IMRT plan eliminating the small bowel in the radiation treatment field.
Some metastatic patients also can benefit from surgical removal of a single lesion in the liver. For others, radio-frequency (RF) ablation may be appropriate. It is another weapon in our arsenal for treating this disease. The Cancer Center participates in most national trials studying new compounds and regimens. Access to these studies is certainly an advantage of receiving care at a tertiary center like UMass Memorial.
Radiation oncology is another area in which UMass Memorial excels. Intensity modulated radiation therapy (IMRT) is "a very important step forward," said Dr. FitzGerald. "We perform IMRT for all GI malignancies, and we are the only facility in Central Massachusetts to do so. This is an exceptional advance for GI cancers because we can avoid damage to the surrounding structures," he added. The ratio of normal tissue dose to tumor dose is reduced to a minimum with IMRT, so that higher and more effective radiation doses can be safely delivered to tumors with fewer side effects compared with conventional radiation therapy techniques.
Palliative options, including stent placement for patients with rectal cancer and RF ablation for unresectable liver tumors, also are available.
There is no question that patients are living longer with colon cancer. But screening to detect it early is a major part of attacking this disease, and this is where the primary care physician plays such an important role.
"Time and time again, we see patients who present with symptoms too late," said Dr. Wassef. "It is now recognized that colonoscopy saves lives through early detection of colon cancer, just as mammography does with breast cancer. We absolutely need to be more aggressive about screening."