A Practical Approach to the Treatment of Metastatic CRC - Episode 5

The Influx of Younger Patients With Advanced CRC

Transcript: John L. Marshall, MD: My least favorite part of my job right now is all of these 30 year olds who are coming into our clinic with colon cancer and no idea why. And it’s not fat, smoker, McDonald’s-eating patients. It’s fit young people. And I know you’re seeing them too. No real idea why. We’re all looking, all trying to figure out is it microbiome, is it cell phones or Starbucks coffee, or whatever. But it’s not MSI [microsatellite instability]. These are not a bunch of Lynch [syndrome] patients, right? And then the other piece is that they frequently present with advanced disease. And I don’t think because they’ve been ignored. I think we’ve gotten a pretty good message out to the community, [emergency department] doctors and primary care doctors that young people can get colon cancer. So they’re getting scoped, they’re getting diagnosed much better than they were say 5 years ago. But on the flip side, I don’t think it’s a quieter cancer. Just because they’re young doesn’t mean it’s a better prognosis. Do you feel the same way?

Tanios S. Bekaii-Saab, MD: I think it is a worse cancer. In some way it makes sense. You have to overwhelm a younger and stronger immune system to essentially escape the surveillance. And, yes, they are harder. They also tend to be more on the sigmoid and rectal side. They definitely tend to be more aggressive. And I think that those patients do worse overall when you expect, on that side of the GI [gastrointestinal] tract, for them to do better.

John L. Marshall, MD: It’s funny, our relationships with our patients change a lot over the course of our treatment of them. You know they come in frontline, they’re terrified. We just get to know them. Hopefully a year or so later is the next time we really have to make a major decision around second line. And so we’ve learned a lot, we’ve learned a lot about their families and their support systems and the [adverse] effects that they’ve had. You know, how many review systems they bring in on a regular basis, how well they’re tolerating things, how many dose reductions. How their response was. These are all things that factor in. And we integrate that. I keep thinking that our job for the moment is secure as humans. That a computer probably would have trouble figuring out what the options are, what the quality of life is like. And the other piece to this is you have a much better educated patient—they know what an infusion pump is like. They know how to get a CBC [complete blood count] and what their CEA [carcinoembryonic antigen] is in a scan and the like. So in some ways it’s evolved into a really nice partnership. And one of the joys of it is that discussion. So, how are you handling this decision around second line?

Tanios S. Bekaii-Saab, MD: I think the word partnership is very important here. We think about our patients as partners now. And I think that means that we have to actually engage in more active discussions than the older model, patriarchal model.

John L. Marshall, MD: I was grumpy a week ago, pretty grumpy, because actually I didn’t think they were treating us like partners any more. I felt like I was being treated like their servant because I asked, “Do you need any refills?” And they said “no.” Some were in clinic, their chart’s open, they said no. An hour later I get an email from one of my patients saying, “Oh, except.” Which means I’ve got to stop, reopen the chart and send the refill. So a shout out to anybody, a patient out there: Be our partner.

Trancript Edited for Clarity