Optimal Treatment for Advanced Colon and Rectal Cancers - Episode 5

Maintaining Wellness After Treatment


Johanna C. Bendell, MD: Shifting now from patients who have completed their treatment to survivorship: What do we do or what do we recommend once somebody has completed their adjuvant therapy? You know we do the colonoscopies and CT computed tomography scans at intervals that are probably very individualized carcinoembryonic antigen [CEA] exams. Our patients always say to us, “Tell me what I can do to decease my risk of this ever coming back. How can I change the way I live?” Heinz, you’re in LA. What do the Californians do for wellness after completing treatment?

Heinz-Josef Lenz, MD, FACP: We have to really focus on what we have data for because I think 1 of the biggest stress factors for patients is that they go to the internet and find all the supplements and juices that cure colon cancer. There are some interesting data coming out—we know the consumption of 2 servings of tree nuts reduce the risk for tumor recurrence.

Johanna C. Bendell, MD: What’s a tree nut?

Heinz-Josef Lenz, MD, FACP: It’s not a peanut, OK? I think it’s all the nuts that grow on a tree, and peanuts do not. They are legumes by definition. I would like to know why that is, and I think there will be ongoing research. We know from the molecular histology of colon cancer that 95% of patients have undergone operations which end up with lowered vitamin D levels. All the patients with colon cancer have low vitamin D. I supplement everyone. Jeff Myer’s group data suggested supplementation is 4000 units, but I give 5000—they come in a capsule that everyone can take. Then the question is exercise.

Johanna C. Bendell, MD: I say 30 minutes 5 times a week.

Heinz-Josef Lenz, MD, FACP: Everything you do that moves your bowels protects, including coffee. The coffee story is extremely exciting because it also includes decaffeinated coffee. It’s not going to the bowel movement. The study looked at how they drink their coffee. In decaffeinated coffee, it’s still protected. So coffee, vitamin D, exercise, and nuts all help.

Zev A. Wainberg, MD: And dieting. Certainly in that, there’s the adhering to so-called less-saturated fat, or more Mediterranean diets. There are pretty good data now showing it would certainly benefit patients. As Heinz will tell you, in Los Angeles, we have many healthy vegan eaters. It’s not necessarily relevant for our patients. Globally, I think dietary adjustments are something every patient should be advised on.

Dirk Arnold, MD, PhD: The most important risk factor is obesity across all tumor types, which includes colorectal cancer. Eating less, eating healthier, prevents obesity. I would doubt whether it makes sense—this is my point—to take it vitamin D because otherwise, if you have low levels in California, this means no one should live long after recurrence of colorectal cancer.

Heinz-Josef Lenz, MD, FACP: It’s a prognostic fact that when you supplement patients, they live longer. There are multiple data sets that support the role of vitamin D. For prevention, the data sets are much lower—but in metastatic disease, it’s shown.

Johanna C. Bendell, MD: They had a randomized phase II study.

Heinz-Josef Lenz, MD, FACP: In the phase II study, the PFS [progression-free survival] was longer. I wanted to go back to talking about food—namely, red meat. The consumption of red meat matches the incidence of colon cancer around the world with 2 exceptions: in Nepal, they eat yak. It’s red meat, but it does not increase colon cancer risk. The Nobel Prize winner Harald zur Hausen found that virus-induced cancers are related to the red meat of cows and not necessarily pork. There are a lot of different hypotheses, but I found these data amazing. There is a gazelle-type animal in Ecuador, with long horns: They also do not increase the risk of colon cancer.

Johanna C. Bendell, MD: So, vitamin D, yak meat, etc.

Zev A. Wainberg, MD: We’ll now see a surge of gazelle and the gazelle industry.

Johanna C. Bendell, MD: As well as aspirin. We have been back and forth about aspirin—taking baby aspirin in special patient populations of colon cancer. What are your recommendations, Dirk?

Dirk Arnold, MD, PhD: That’s a difficult treatment to preach. We have strong supporting data that shows that there is no benefit. We had the discussion on the phosphoinositide 3-kinase; we discussed Lynch syndrome patients, etc, about whether they would benefit from this. My personal interpretation of the data and core recommendation is, I do not see a role.

Johanna C. Bendell, MD: Sounds good.

Transcript Edited for Clarity