The Divide and Conquer of Advanced Colorectal Cancer - Episode 4
Transcript:John Marshall, MD: Let’s shift gears a little bit. Let’s talk about really another amazing phenomenon that has happened over the course of the last 10 to 20 years, and that is curing metastatic colon cancer. None of us are doing it. The surgeons or our other friends in interventional radiology, etc, are doing that. And Tony, I’m going to let you set the stage for us here. When thinking about patients with oligometastatic disease, and we’re primarily thinking liver metastases here, how do you manage that? How do you do treatment decision making? What’s the process in a great place like the Mayo Clinic to get that patient to no evidence of disease?
Tanios Bekaii-Saab, MD: This is an interesting subgroup of metastatic colon cancer, this whole oligometastatic group, that has the potential for a cure and also the potential to be disease-free for quite a while, meaningfully. And that has essentially changed even the staging of colon cancer—stage IV into stage III a, b, c—based on the fact that we know these behave differently. So, metastatic colorectal cancer that travels to the liver is a unique disease because, again, the colon drains to the liver through the portal vein so it could be the first stop before the cancer cell travels systemically. And so, unlike other cancers where you have to use the bloodstream to get to the liver, these may be direct metastases. There may be other mechanisms, of course, but this uniqueness actually has led to thinking that this group of patients could actually be potentially curable through removing the portion of the liver that’s involved. And even for some smaller tumors, apply modalities like radio frequency ablation or even there are emerging data with radiation SBRT (stereotactic body radiation therapy). So, those patients—this is why it’s so important for patients like these, meaning patients with metastatic colorectal cancer that have metastatic disease to the liver only or also you can include the other oligometastatic disease—need to be referred to a hospital or an institution that essentially has a multidisciplinary group that deals with these instances. Because those patients actually have a 20% to 30% shot at a cure.
John Marshall, MD: And I think the oncologists listening in right now need to understand that that’s our job to identify those patients. The radiologists aren’t making this call, and it’s not like the surgeons are reviewing these scans. We’ve got to know enough to identify and refer and use our team. Johanna, when you’re seeing a patient—I know when I do this, I get a warm feeling that maybe, just maybe, we’re going to do something good here—talk a little bit about the language, the discussion you have with the patient. Do you use the C word, “cure”? How do you manage that discussion?
Johanna Bendell, MD: I do have to say that when you have this patient that comes in, they’ve got this new tragic diagnosis, the patient sitting in front of you has metastatic colorectal cancer. And it depends. The strength of the language I use depends on how much liver disease they have. There are some people that are liver-only that, at the highest likelihood, you’re not going to cure these patients. Then, there are ones where you could potentially cure them if you give them good chemotherapy and they get enough tumor shrinkage. And then there are ones that you can cure right away. For the people who have this oligometastatic disease where we think we might be able to cure them right away or with minimal chemotherapy, I use the C word. It’s something where we say, “We’re going to try.” And I do give them the percentages—25% to 30% of patients still had a chance at cure—because I think that helps with the motivation that they’re going to see all these extra doctors, potentially have different tests done, MRIs, try to get that chemotherapy in for that chance of cure.
John Marshall, MD: So, I even use this, similarly to you. If it’s the bad side of things, I’ll use the language of, “Well, the only way we know to cure your cancer—this is a brand new diagnosis—is surgery.” And, of course, the problem with that is then everybody wants surgery and you have to talk them back from that. We do now use it. Alan, are you using the C word in the clinic?
Alan P. Venook, MD: I do use it often. What I’ll tell patients, especially early on in their disease—unless with peritoneal metastases or some huge metastatic burden—is “No.” But the patient who has modest burden or oligometastatic disease, the way I’ll frame it is, “Our goal is to cure you until proven otherwise.” And, of course, one of the things I’ve learned is always to be honest with patients, that way you don’t have to remember what lies you told them, therefore you know what you said before. The frustration, I think for me and for probably each of us, is in the practices we have, which are referral practices, when you see patients where there was an opportunity to make a big difference and it was missed. These are patients you can’t use too much chemotherapy in. You get fatty liver. You may not be able to do a resection. You don’t do 12 cycles of FOLFOX. You need to look earlier. These are things that are very frustrating because if you miss that opportunity, that’s where you make a big difference. And I agree with the numbers that have been used. For about 25% to 30% of patients, you actually get that opportunity.
John Marshall, MD: In the right setting. Let’s be clear about this: so, a few metastases, maybe unilobar metastases, responding to chemotherapy. There are some publications on the perfect patient—60% 5-year disease-free survival…
Alan P. Venook, MD: At Memorial Sloan Kettering.
John Marshall, MD: And at Johns Hopkins. These are where you get your cures that way, but the rest of us are a little more humble. Humility is a good thing.
Transcript Edited for Clarity