Rectal Cancer: What You Need to Know with Dr. Emre Gorgun

Podcast Transcript

Scott Steele Butts & Guts. A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi everybody, and welcome to another episode of Butts n’ Guts. I'm your host Scott Steel. I'm the chairman of colorectal surgery here at Cleveland Clinic in Cleveland, Ohio. Today we're going to talk about rectal cancer, and I'm very pleased to have Dr. Emre Gorgun here who is one of our staff colorectal surgeons. He's the Krause-Lieberman Chair in Minimally Invasive Colorectal Surgery. Emre, welcome to Butts & Guts.

Dr. Emre Gorgun: Thank you very much, Scott. It's a pleasure to be here and thanks for having me.

Scott Steele: For all the listeners out there, we'd like to start these with a little bit about yourself. Where you from? Where did you train? How did you get to the point where you wound up here in Cleveland?

Dr. Emre Gorgun: I was born in Istanbul, Turkey, overseas and moved to Cleveland Clinic about 15 years ago. I was trained here at Cleveland Clinic. Then I did a little bit more training in Cornell in Memorial Sloan Kettering in New York. And I came back here to Cleveland Clinic as fulltime faculty since 2011. I've been on the faculty here and really enjoying it.

Scott Steele: Today we're going to focus on rectal cancer. You've done a lot with rectal cancer patients; you've operated on a lot of rectal cancer patients. But let's start off by saying how does most rectal cancer present?

Dr. Emre Gorgun: I think first we need to probably start saying what is the rectum? It's the very lower portion of our intestinal track. The cancers of this anatomical location are referred to as rectal cancer. And how they present is if there is a lesion or abnormal tissue structure in this area, it can present most of the time as bleeding. Rectal bleeding is one of the main things we need to watch out for.

Scott Steele: So lots of symptoms happening in there. I always try to tell my residents and my trainees, my fellows out there, that if you have something wrong with your arm, what do we do is we look at our arm. But, as you said, this is the last few inches of our GI tract and it's very difficult to kind of look and see what's going on, and all of this is originating up inside. You mentioned bleeding, and I know that some patients may have pain or they may they may have some changes in their stool, but is it a worry if you have pain or bleeding, or changes in your stool, that you have rectal cancer?

Dr. Emre Gorgun: Not at all, not at all. But these are some red flags that we need to be aware of. These are some signs that you need to seek some help or go to see a physician. You certainly need to see a healthcare provider if you are having one of these symptoms.

Scott Steele:  I think that's a crucial aspect that we need to make sure we're not saying, by any stretch. As a matter of fact, in the majority cases it might be hemorrhoids or a fissure or something else. But in this case you don't want to ignore the symptoms; you want to make sure that you take a look at that. So what causes rectal cancer?

Dr. Emre Gorgun: There can be many various factors like smoking, obesity. The main thing is the genetics and changes in the lining of our intestinal tract. Some mutations lead to abnormal tissues we refer to as polyps or precancerous lesions. They are like a mushroom-type of lesions initially, or they can look also flat, but they can turn into some abnormal tissues which can lead later on to cancer.

Scott Steele: You say that there's a genetic component to it, so we need to know what our family has in there if we have a family history of that. There's some lifestyle things. What comes up, oftentimes, is what is the role of red meat? Should I eat red meat? Is that going to cause me to have rectal cancer? Or should I eat on the other end of it, if I ate all my fruits and vegetables and fiber? What is it about those two different extremes, and how do they relate to rectal cancer, if at all?

Dr. Emre Gorgun: There are different studies on those. What we know is that having a healthy diet is very important. What we mean by that – and we always emphasize when we say to patients,  I'm sure you do the same thing – is a fiber-rich diet, more vegetables, maybe more like what we call a Mediterranean diet. Definitely rich in this type of element in the diet is the best thing. Yes, there are studies showing red meat can contribute to this, smoking definitely, obesity. These are the things that we should be aware of. That doesn't mean everyone who eats meat gets cancer. But everything needs to be consumed in moderation. So nothing in excess.

Scott Steele: So I'm a patient, and I've experienced some changes in my bowels, or I'm having some bleeding or even a little bit of pain. What can you expect from a trip to the doctor, to a colorectal surgeon, or even your primary care doctor, and how is this evaluation going to progress?

Dr. Emre Gorgun: When you present to your doctor, certainly, be prepared that you’re going to be examined. It's very important to have that type of an examination. Depending on the character or features of your rectal bleeding, you may get an anal area exam, or maybe even what we call anoscopy or proctoscopy – very quick, pain-free examination in the office setting. Your physician should take a look inside and make sure that there's no abnormal tissue in the rectal area. I think also one other thing that we need to certainly mention here is screening colonoscopies, especially for people who are over age 50. It's very important and we cannot emphasize enough how important a screening colonoscopy is. Anyone who is over 50 should get their colonoscopy done. This is shown to be a huge factor in preventing colorectal cancer. Every year 140,000 patients are diagnosed with colorectal cancer in the United States, and it's a huge number. And it's a huge disease that we are facing. Colorectal cancer is a curable disease if it's diagnosed in a timely fashion and treated in a correct way. Note: as of May 2021 anyone age 45 and older should get a screening colonoscopy.

Scott Steele:  Every year it is between the second or third cancer-related death in the United States alone, depending on the year. So let's kind of progress back to the patient who comes in. I know that I'm going to come in and I'm going to get maybe a digital examination. I may get a small scope that's placed up the rectum to be able to take a look and examine that area. But take me the next few steps, how is rectal cancer diagnosed? And if it is diagnosed as rectal cancer, what are the following tests that I could say that I'm going to have to completely work that cancer diagnosis up.

Dr. Emre Gorgun: When you have rectal bleeding or any changes in your bowel habits, it’s very important to come to a doctor. That doesn't mean you have it, but let's say you have a suspicious problem or a concerning issue in the rectum, then you’re going to have to be examined. And at that time a scope will be placed. If the physician is worried about any concerning lesion in the rectum, then certainly you can expect that physician will ask for further studies that may include some imaging. The most common imaging is the MRI. Of course full colonoscopy is probably going to be the first thing before even imaging technology. Let's say you are already diagnosed with a suspicious lesion that is most likely abnormal tissue or cancer. After this area is found, a biopsy will be taken. A pick or forceps is going to reach into that area and this small tissue will be sampled and will be sent to pathology to be looked at under the microscope. If that finds any abnormal tissues or cancer, that would mean that patient might have an invasive cancer diagnosis. Imaging modalities are going to follow, which is MRI, pelvic MRI, as well as a CT a CAT scan of the whole body. That should include what we call staging of the cancer, whether we have other areas involved.

Scott Steele: What we're talking about here is determining the severity or the extent of the disease. I think what the most important take home points are how advanced is the disease locally, where it's placed in the rectum. And then has it spread to other layers of the body. I want to go back and touch on a couple of things you said. We know that here at Cleveland Clinic a lot of patients will get their MRI. Let's say I grew up in a small town and I don't remember having an MRI around. What about our listeners out there who may not necessarily have access to an MRI? Are there other modalities or tests that they can get to look at the local staging in the rectum itself to see how advanced it is into the wall.

Dr. Emre Gorgun: Absolutely. We used to use even more often another modality called endorectal ultrasound. That actually was the gold standard that before MRI became more popular. Alternatively, pelvic ultrasound or rectal ultrasound can be used. It's good in determining how deep the lesion is penetrating in through the wall in the rectum, as well as sometimes even to see if they're in the lymph node, or if a tumor spread in the deep tissues. So these are two areas that ultrasound can be used if the MRI is not available.

Scott Steele: Another thing that oftentimes comes up that you might read about in a newspaper or in a book is this concept of a PET scan. Does everybody need a PET scan to look at their rectal cancer?

Dr. Emre Gorgun: That's a very good question. A PET scan, unfortunately, I believe is overly utilized and used. And it's an expensive test and not really necessary most of the time. PET scan is not part of standard staging radiological imaging in this era. Yes, PET scan has a role, but these are really selected cases and it should be used when needed.

Scott Steele: I'm that patient that comes in and I get my full staging workup, what are the most common places that if rectal cancer were to spread elsewhere in the body, where would they go to?

Dr. Emre Gorgun: Rectal cancer would go first to the lymph nodes, which are the small lymphatics or areas where the cancer cells are trapped. And these are what we refer as local areas. So it's right behind the rectal organ in the blood supply area deep in the pelvis though. So this would be the first station, if you will. Then cancer cells can travel along the vessels all the way up to the liver. Less common areas of spread could be the chest or the lungs, or even in the bony areas, and so forth.

Scott Steele: You and I are surgeons, and I know that a lot of patients will come in and they will say that “I was diagnosed with a cancer and I just want it out. Just get it out of my body,” and I can understand that sentiment. But let's talk a little bit about treatment now for rectal cancer. Obviously, there are multiple different ways to treat cancers, and we talk about chemotherapy, we talk about radiation therapy, we talk about surgery. Talk a little bit about rectal cancer treatment and how do those three modalities or those three different service lines fit into the treatment for rectal cancer.

Dr. Emre Gorgun: It's a very combined approach now. These treatment modalities cannot be discussed separately. Depending on the stage of the tumor or how extensive it is locally, the best treatment option is now giving the chemotherapy and radiation just before we operate. And that's five-and-a-half weeks of treatment modality. Again, the radiation is given into the pelvis very locally to affect the rectum, and with combination of a little bit of chemotherapy. The role of the chemotherapy in these circumstances is to make the body more sensitive, more acceptable or receptive to radiation, and make the radiation do its job in a better fashion. And really, it does it work very effectively. Sometimes when we go in, the tumor is very small or in some circumstances even completely gone. But still it is a part of standard treatment of care. We wait after the treatment is completed, about eight weeks or in some circumstances 10 weeks, and then do our operation, which is removing that organ and most of the time putting things back together.

Scott Steele: So you brought up a couple of interesting things there. And again I think it's worth pointing out that here at Cleveland Clinic we have a multidisciplinary tumor board, where all of our colon and our rectal cancers and all of our cancers discussed and talked about. What we're talking about today, in terms of some of these treatments, are a generalized patient. I think it's important to understand that for anyone out there that's listening, that may be going through this or may have gone through this, or you know family members that are going through it, that there are obviously some individual variations in the form of treatment. But you brought up a couple of things. Is that in general if you have somebody that's maybe a little bit larger tumor, a little bit more locally advanced, they are going to get their chemo or their chemo/radiation therapy up front? And then there's that break. What is the reason for that break? As you said, sometimes that's two, two-and-a-half months – that’s a long time. Patients oftentimes get a little bit concerned about that break. But what's the rationale for that?

Dr. Emre Gorgun: We know that the waiting adds time that what we call cumulative or added value of the radiation. So the longer you wait, the radiation can have more time to get the cancer smaller. So it does its job. We did do studies which showed us that optimal time is at least about eight to 10 weeks.

Scott Steele:  I’m the king of bad analogies, and I like to tell my patients that just like if you go out in the sun, I'm a fair skinned person. If I go out in the sun and just because I leave the sun I could still have effects of that sun afterwards. Radiation therapy continues to have those effects even after you've completed that, just like that sunburn that comes on after you're out of the sun. Now we're up to the time of surgery. So can you do this operation through a minimally invasive approach? I know there are some very select patients that might not need to have the whole rectum removed and may be able to go through the rectum and just have that portion of it. Can you talk about those two things?

Dr. Emre Gorgun: I'm glad you asked me this question. We are a very specialized center and we are gladly helping our patients in these circumstances. Minimally Invasive surgery is a passion of mine, and we do perform more than 250 cases a year of these in a minimally invasive fashion. For very early rectal cancer, certainly we don't even have to remove the rectum. We can just go almost like a keyhole surgery from the anus approach and put special devices in – we put a camera going through the anus into the rectum and find that spot and make a cut around it and remove it with clear margins. But when we need to remove the entire rectum, even in those circumstances, there are options. We can do these laparoscopically, minimally invasively. Laparoscopically means putting little cameras around the belly button through other puncture holes. We get in and remove the rectum and put things back together, making a reconnection again. We can reconstruct the intestinal tract and patients can have bowel movements through the normal route again. Another option that we very widely use is robotic surgery. We can do minimally invasive surgery and use the daVinci robot, or any newer robots, and get into the abdomen, get into the stomach again, using these small cameras. Using a robotic tool we can really make a three-dimensional view and enhance visualization. We can get to the abdomen and remove the rectum again very effectively, and again put things back together, meaning reestablish the anatomy so patients can use their intestinal tract again. In this case, I think I need to mention it is sphincter preserving. For tumors that are very low rectal tumors, it is very important if your doctor tells you that you need to have a permanent bag, it's good to maybe seek a second opinion. There are many specialized centers who are preserving the control muscles or sphincter muscles. It’s an option using these minimally invasive techniques, potentially allowing us to be more precise down in the lower areas and preserve these control muscles.

Scott Steele: I think that's one of the common questions that I get is does rectal cancer mean that I have to wear a permanent bag? Which we would also call a stoma or an ostomy, a colostomy. And I think that is important for all the listeners out there to understand that in certain cases that's the right thing to do to remove all the tissue. And that may include, essentially, that permanent bag that you may have to wear. But there are other instances where we may be able to re-hook up the bowel. So the bowels could be normal in the future, but that may even involve having a temporary bag. While after the surgery you get the completion chemotherapy and subsequently get the bag removed. That is a quick walk through rectal cancer. What is the typical follow up after rectal cancer for the first few years that patients can, in general, understand that they're going to be able to go through?

Dr. Emre Gorgun: After their chemo is finished and the temporary ostomy is closed, then they go back to their normal routine without any bag. Some may have to have permanent bag. But regardless which operation they get, certainly they need to be monitored closely. Typically we do office visit initially every three months to six months with imaging with CAT scan or CT of the abdomen and pelvis. It's important to monitor the rest of the colon and rectum, what's left behind, with colonoscopy. The standard screening for that is one year. And then after if that's normal, the next one would be three years after the last colonoscopy.

Scott Steele: We like to see our patients at regular intervals so we can just make sure that they're undergoing proper surveillance.  Emre, I like to end all of my interviews with my guests with a couple of quick hitters. Very quickly, what's your favorite sport or activity?

Dr. Emre Gorgun: Sailing.

Scott Steele: And what's your favorite meal?

Dr. Emre Gorgun: Gyro.

Scott Steele: And the last book that you read?

Dr. Emre Gorgun: Emotional Intelligence.

Scott Steele: I like it. What is the best thing that you like about Cleveland or one of the best things you like about living in Cleveland?

Dr. Emre Gorgun: Lake Erie.

Scott Steele: If you can sum up rectal cancer very quickly, 10 words or less, sum up rectal cancer.

Dr. Emre Gorgun: Nothing to fear if you have a problem, come to us.

Scott Steele: Thanks so much for joining us here on Butts N’ Guts. To sum this up, rectal cancer is the second or third leading cause of cancer-related death in the United States. To learn more please download our colorectal cancer treatment guide at clevelandclinic.org/colorectalcancer. To make an appointment with a colorectal cancer specialist here at Cleveland Clinic, please call 216.444.4673. That wraps things up here at Cleveland Clinic. Until next time. Thanks for listening to Butts and Guts.