What to Know About Colorectal Cancer Surgery

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Super excited to have one of our own in the department of colorectal surgery, and that's Dr. Arielle Kanters, who is a staff colorectal surgeon and also the associate program director of our colorectal surgery fellowship here at the Cleveland Clinic. Ari, welcome to Butts and Guts.

Dr. Arielle Kanters: Thank you for having me.

Dr. Scott Steele: We always like to start out with a little bit of background and although I know it, the other people don't. So, tell us a little bit about yourself. Where are you from? Where did you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Arielle Kanters: I am a Midwesterner, through and through. Born and raised initially in the Chicago area. Then actually came to Cleveland back in the early 2000s for both college and medical school. Then I traveled to that state up north that we're not allowed to mention in Ohio, but some know it by Go Blue! I did my surgical training there, and I was fortunate enough to get the chance to come back to Cleveland for my fellowship training. I re-fell in love with Cleveland and was given the wonderful opportunity to stay on for an additional advanced training year, and now I'm here for good.

Dr. Scott Steele: We are super excited and privileged to have you stay on with us. Let's talk a little bit today. We're going to talk about colorectal cancer surgery and basically colorectal cancer treatments in general. At first, we've had some different podcasts on this in the past, but for those who haven't listened, give us a high-level overview of colorectal cancer and how this disease can affect someone's colon and or rectum.

Dr. Arielle Kanters: Colorectal cancer is one of the big things we treat in colorectal surgery. It's one of the things I really enjoy because I've got a real chance of curing cancer in my patients. What a cancer itself is, is essentially an abnormal cell that escapes and starts to just replicate, replicate, until it turns into a tumor. If that tumor gets even bigger, it can start to spread to other parts of your body. With colon and rectal cancer, specifically, this is the inside lining of the colon that can form into a pre-cancer or a polyp. Then, if it continues to have changes in its genes, it can turn into a cancer, and eventually if it spreads past the wall of the colon, it can spread to other parts of your body.

Dr. Scott Steele: Ari, we talk a lot about colon versus rectum. Can you just tell us a little bit about the difference between those two?

Dr. Arielle Kanters: Absolutely. The rectum is the last part of your colon essentially. Your GI system goes from your mouth to your stomach to your small intestines; small intestine hooks into your colon and then finally ends in the rectum and comes out the bottom. We actually talk about colon and rectal cancer usually together, but in terms of our therapies, it really matters which one we're talking about. For colon cancer, we think about surgery up front. For rectal cancer, we actually have a little bit more of a nuanced initial treatment, thinking about whether they need surgery or they might need chemotherapy or radiation right up front.

Dr. Scott Steele: We're going to get into that a little bit later. We talk about screening versus diagnosis, everything. How do we figure out those terms? Then who should be getting screened for colorectal cancer?

Dr. Arielle Kanters: Average person you meet on the street, first time they should be getting screened is at 45 years old. This is actually different. It used to be 50 years old. That's what a lot of people still think it is, but we've seen younger and younger people being diagnosed with advanced stages of colon and rectal cancer. Fortunately, we've gotten the opportunity to start screening them earlier. Now, that's your average risk person. If you have a family history of colon or rectal cancer, if you or a loved one has a family history of polyp disease or inflammatory bowel disease, that actually changes your risk. It can increase your risk, and in those situations, you may actually need a colonoscopy or colon cancer screening earlier in life.

The other thing is not only from a screening standpoint, but from a diagnosis standpoint, if at any point you start having blood in your stool, changes in your stool, things like that, I highly encourage you to see your PCP or your primary care doc and hopefully a colorectal surgeon or a GI doc to again be evaluated for whether or not you need a colonoscopy, as well.

Dr. Scott Steele: It's important to understand exactly that in many of these cases it is a benign cause, but don't ignore the symptoms and make sure you bring it up with your healthcare provider and then make a determination of whether to have more diagnostic procedures such as a colonoscopy. We talked a little bit about diagnosis versus screening, but let's focus on colorectal cancer right now. Understanding what I just said, that some of the symptoms may overlap, what are some of those symptoms of colorectal cancer?

Dr. Arielle Kanters: The one that we hear usually most often is rectal bleeding. If you're passing blood pretty much at all, like Dr. Steele has just said, please talk to your primary care doc or whoever provides your primary medical attention because that's something that we need to be aware of. Other symptoms we can see are changes in your bowel patterns. You start to have worsening constipation. You notice that the quality of the stool is changing. It went from being a normal size to something skinny like a pencil. Other kind of more non-specific symptoms would be things like weight loss, worsening fatigue, early sense of feeling full. All of these things should kind of let a little red flag go up that you should be talking to your primary about these.

Dr. Scott Steele: Fantastic. Now, we jump into a quick question, truth or myth? Truth or myth: the only way to detect if you have colorectal cancer is by getting a colonoscopy.

Dr. Arielle Kanters: For many patients, they'll be happy to hear that's a myth. There are a lot of ways that we can do your screening. We, as colorectal surgeons and as GI docs, the gold standard is a colonoscopy. The reason we really encourage those is because they both help us diagnose but also help us treat. It's a diagnostic and therapeutic test, meaning that when we do the colonoscopy, we can not only look for things like a cancer or a pre-cancer polyp, but we can remove these, which hopefully would prevent a pre-cancer ever turning into a cancer in the long run.

The good news, though, is that there are other options. That includes things like stool studies, where we can look for things like blood in your stool. We can look for stool DNA tests where they can look for abnormal DNA, which would potentially be shed by either pre-cancerous or cancers. We have some CAT scan options, a CT colonography. Now, what's important to know, and again you can talk about all these with your primary, each of these kinds of has different restrictions. Certain ones have diet restrictions. Certain ones you need to do a bowel prep for. Certain ones you won't be eligible for if you have any family history or increased risk. Pretty much anyone but a colonoscopy you will not be eligible for if you have increased risk. Then the other thing we can sometimes offer rather than a full colonoscopy is a mini-scope or a flexible sigmoidoscopy. This is used in conjunction with some of the stool studies, as well.

Dr. Scott Steele: I just want to emphasize something that she said: if you do see abnormalities on some of these other tests that then going on to a colonoscopy to be able to evaluate and make sure that what they did see was indeed there. And then whether or not we can intervene on it through the scope or if it warrants other things such as surgery or some of the other things we'll talk about.

Okay. Hearing the word cancers scary. We know that. I mean, it can rock your life and rock everyone around your life. I'm a patient and I was just told that I had colorectal cancer and I've got to go see Dr. Kanters. What should a patient expect when they see you? Walk them through that first or those initial therapies and then during and then after surgery, if indeed they are somebody that has surgery. We'll focus a little bit now on majority of colon cancer. We'll get into rectal cancer just in a little bit.

Dr. Arielle Kanters: All right. Obviously, this is a terrifying, very scary thing to hear. You have cancer, you have to see a surgeon. One of the first things, at least with my patients, I kind of want to lay the groundwork. The good news is that in most situations, colorectal cancer is very treatable, and it's something that we can cure. In that first initial meeting, we go through their staging. We have to figure out what has been diagnosed at this point. Have they only come in with a colonoscopy and they've gotten a single biopsy? Has someone already gotten CAT scans? One of the first things you can expect after you hear that you may have a colon or rectal cancer is that we're going to get CAT scans. We're going to check your chest, your lungs, we're going to check your belly, look at your liver and make sure we don't see any evidence of disease anywhere else in your body because that will really change what we can do next.

Other things that we do in that first appointment is we would get a set of labs. We want to check your blood counts; we want to see how your liver's doing. We want to check for certain things called tumor markers, which is something that'll help us in the long run keeping a close eye on you after your surgery. Other important thing, I just want to get to know you. I want to know what medical problems you have. What surgeries have you had? Because all of this will affect my planning in what we can do safely to get you to being cured of cancer.

Finally, depending on where the lesion is, where the tumor or the cancer is, we may even do a mini scope. This is actually a really important thing and something I'm trying to highlight with patients, maybe even before they come in, is that fortunately at The Clinic, we have a wealth of resources, and we can actually take a look at this cancer if it's low enough down while you're in clinic to make sure that we're not missing part of the story. Occasionally, if a patient comes into our clinic, we may even talk to them about doing a mini scope same day.

Once we have a sense of what the stage is, we talk about what our surgery options are. For colon cancer as we're going to start off first, most of them, if they're stage 1, 2 or 3, we're talking about surgery up front. Stage 4, which means it's spread outside of the colon, outside the lymph nodes is a slightly different situation, and we can talk about that later. You might have chemotherapy first, but for the first three stages what we do is we take you to surgery and we try to remove the cancer. I talk to you about what kind of surgery we're going to do.

If you're healthy, you don't have a bunch of medical problems, hopefully it's a one-and-done surgery. We remove the cancer, we put the colon back together and then we get to talk about what the next steps in your treatment are. Occasionally, we may have to talk about something like a temporary bag, and that would be a big part of that first conversation that you and I would be having in the clinic setting. I know that's a really scary thing, but I can tell you that our patients do amazing. We have incredible stoma nurses, so a bag or an ostomy is something you sometimes hear about. We have you seen by our stoma nurses, and we make sure that you feel comfortable with what may have to happen in the operating room.

Then during surgery, that's probably the easiest part for you, yourself. You're sleeping the whole time. You come into the operating room; we introduce you to everyone in the operating room. We have an incredible team here at The Clinic that we get to work with day in, day out. When you wake up, I'm happy to tell you, hopefully the cancer is gone.

Usually, like I said, we can put you back together right off the bat. What I mean by that is we remove the cancer and then we reconnect the colon back to itself. Under certain circumstances, we have to talk about a temporary bag, but those are usually the outliers when it comes to colon cancer.

Then starts the hard part, the recovery from surgery. Generally, if it's a straightforward operation, we connect you I'd say three to five days after surgery. The big things that keep you in the hospital are making sure your pain's well controlled, make sure that your bowels are functioning. So, I want you passing gas and having bowel movements, know that things are working their way through. We want to make sure you can keep yourself hydrated and you can keep nourishment in your body. So, protein shakes, rehydration fluids, things like that. We want to make sure you're going to be doing good. Then fourth, if you have a stoma or a bag, we want to make sure you're comfortable managing it.

Then, after surgery, you come back into clinic, and we can actually talk about our pathology. Once we remove the tumor or the cancer, we have our pathologists look at it and they take very, very thin slices of everything and look at the whole specimen. They look at the lymph nodes, they look at the cancer, and they look to make sure that there's not any high-risk features. Depending on how deep the tumor goes into the colon or if there's lymph nodes, we can give you a final stage and that will determine whether or not you need chemotherapy after surgery.

Dr. Scott Steele: Just to be clear on this staging thing, if I heard you right, you said that the stage 4 is when it's spread elsewhere. Can you tell stage 1 through 3 before surgery or is that typically done after surgery?

Dr. Arielle Kanters: It's typically done after surgery. The big difference between stage 2 and stage 3 is whether or not there's any lymph nodes involved. Occasionally on those CAT scans, we can see some areas that may be more concerning for a lymph node, but it's really not until after we remove the tumor that we can tell you for sure what stage you are.

Dr. Scott Steele: Just for all the listeners out there, I think it's important: if you have heard about the term of endoluminal surgery and taking out early cancers through the scope, I encourage you to go back and listen to Dr. Gorgun and Dr. Bhatt, who've been on in the past with us and look at those old episodes. A lot of wealth of information there.

Now let's switch gears really quick, even though we are one long garden hose from our mouths to our bum, and let's focus on that last portion of it, the rectal cancer, where we do exactly what you said is we take a look with a camera there in the office. That's treated, as you said earlier, you kind of hinted at, a little bit different in some cases where maybe we start to bring in some other of the therapies and a multidisciplinary team to that. Tell me a little bit through, again, we get the staging's a little bit different and the tools we use, not the actual staging itself, but the tools we can use and then those other components to it. What is that all about?

Dr. Scott Steele: Rectal cancer is a really interesting thing to talk about, particularly in the last 10 years where we've seen a bunch of changes in how we have been managing it. Historically, it was much more like colon cancer where we operate right up front. But what we've actually seen is that we have much improved long-term survival rates for most patients if we give them radiation.

For a while now, anyone who's a stage 2 or above actually will get radiation with some chemotherapy mixed in right off the bat, meaning we don't go to surgery first, but we actually deliver an anti-cancer therapy before we do any operations. Now more recently what we're seeing is if we deliver that in conjunction with chemotherapy agents, so you get a radiation treatment followed by chemotherapy or vice versa, that we're actually seeing almost 25 percent of patients are having a complete response, meaning that their tumor completely disappears to the point we can't see it on MRIs or on scopes.

There's this whole new realm within rectal cancer where we may not even need to operate, at least early on, and some people can save themselves a really invasive operation. What's really important to recognize in all of this, is this is still really kind of new and fresh information. It's called a watch-and-wait protocol. You have to be followed very, very, very closely if you do fall into that lucky fraction that actually have a full response after chemotherapy and radiation. The vast majority still go on to surgery, still maintain that standard of care, which is we remove the whole cancer and the lymph nodes associated with it.

Dr. Scott Steele: That's great information spelled out very well. A lot of times patients will go around, they'll be like, yeah. That sounds good and everything, but I want to go check out a second opinion. What's your take on second opinions?

Dr. Arielle Kanters: I'm very much for them. So verbatim, I tell my patients what I tell my six-year-old: your body, your decision. I want you to feel comfortable with the decisions that you are making and having people help you make. If you don't feel comfortable with what the first person you talked to said, go talk to someone else. They may agree, they may disagree. But the point is you'll be able to make a more informed decision. I always caution patients in terms of what they do on the Internet, but look for reputable resources. Look at the Cleveland Clinic website. Everything that we publish and put out in terms of patient information has been vetted by our physicians and our practitioners. Absolutely, do what makes you feel comfortable, and make sure that you feel like you've had all the information presented to you before you make your final decision.

Dr. Scott Steele: Ari, when my mom was alive, she'd come back from the doctor and I'd say, what'd the doctor say? She said, nothing. I'd be like, he didn’t say or she didn't say anything? Nothing at all? She would say, I didn't know what to ask. I used to struggle with that question. But a lot of patients, they just don't know what to ask. Are there important questions a patient should ask before receiving colorectal cancer treatment and or surgery?

Dr. Arielle Kanters: Absolutely. Do your homework. If you get this scary cancer diagnosis, make your appointments first and foremost, but start to look at some of these websites like the Cleveland Clinic website. The things you want to ask, you want to ask, first of all, what stage am I? What does that mean? Does that mean surgery? Does that mean chemotherapy? What is my five-year survival rate? Because that ranges significantly even within a single stage. Being stage 2 and stage 3 can mean very different things depending on different parts of your cancer pathology. You want to have a better understanding of, what do the next six months, what does the next year look like for me? You want to ask, what are my surgical options? Will you be doing this with a big open incision? Can you do this through little incisions? Can you do this using the robot?

Each surgeon or physician that you would meet may have a different preference and it's important to hear them out. You always want to make sure that they are comfortable with your operation. That's another really important thing. I think asking how many they've done isn't always the best question, but you can ask that if that's what's ultimately going to give you the vote of confidence that you need to proceed.

Dr. Scott Steele: In terms of, we touched on this a little bit earlier, but the horizon as far as colorectal cancer treatments, and you spoke a little bit about the watch-and-wait protocol, the actual non-operative protocol for rectal cancer specifically. Can you talk about, just in overview terms, of what are the criteria that you use? How do we know that somebody will be able to meet that criteria to go ahead and not get an operation? Or whether a doctor will give them a choice and say, we can enter you into this protocol. You can still have surgery, but you can enter into this protocol. What criteria do you use?

Dr. Arielle Kanters: Well, first of all, and I realize I should have probably mentioned this earlier, every cancer patient that comes through here, we discuss in a multidisciplinary team meeting. What that means is we have pathologists, radiologists, oncologists, radiation oncologists, surgeons, all working together because we all collectively treat cancer as a team. Anyone who has the opportunity to be enrolled in a non-operative protocol, that would be part of this team-based discussion because we all have to be working together to make sure that we don't let something fall through the cracks.

Generally, someone has to have completed a total neoadjuvant therapy, meaning they have completed their radiation which has a little bit of chemo mixed in. They have to complete their chemotherapy, and we have to see both endoscopic complete responses, meaning that when we do a scope and we do an exam with our fingers, we don't see or feel any evidence of cancer and they have to have a radiographic complete response. Meaning that when we get an MRI, because MRIs are the most sensitive, they really give us the best idea of what's going on in the pelvis, the MRI doesn't show any evidence of residual disease is what we'll call it. That's really what we need to see. Then we have that full discussion with the team when we say, all right, this patient does seem like a good candidate for a watch-and-wait or a non-operative protocol, and then we present it to the patient.

One other really important thing, we need to know the person that we're enrolling is going to follow up. We know that we can treat this with surgery, but we need to know that if we're not going to the operating room, that we're going to have an opportunity to catch it if there is any evidence of disease in the future.

Dr. Scott Steele: Two questions on that. The first one, I've got a brother that's a Nervous Nellie, and let's just say that he had rectal cancer and it went all the way away. Can he still have an operation?

Dr. Arielle Kanters: Absolutely. That's the thing. It's kind of funny being a surgeon, and here we are offering a non-operative therapy. There's kind of this internal conflict here. We know the gold standard is surgery. But there are a group of patients who potentially can get away without an operation.

Rectal cancer surgery is different than colon cancer surgery. Like I said, we talk about the colon and rectum in continuity, but in reality, the rectum works differently. When we remove some of it, this may affect your long-term quality of life in terms of your bowel habits and how you go about your day-to-day. Removing someone's rectum does carry a little bit more risk than removing just a portion of the colon. If you want surgery, by all means. We are surgeons, we love to operate, we will always offer that. But if you fall into this small category and you're a willing participant and you know you feel comfortable and confident with the idea of just observing, absolutely we can work on that.

Dr. Scott Steele: Then the second question is, we want to make sure that watch-and-wait rectal cancer - is there, watch-and-wait for colon cancer?

Dr. Arielle Kanters: Nope. Surgery. Like I said, I love treating colon cancer. It's great. We can cure. These are the patients that, because we offer surgery upfront, these are the patients were watching and waiting isn't going to be an option.

Dr. Scott Steele: Okay. Now it's time for our quick hitters where we get to know our guests a little bit better. Ari, what's your favorite food?

Dr. Arielle Kanters: Oh my gosh, that's harder than any cancer question you've asked me so far. Depends on the day. Usually, sushi versus just good old tacos at home.

Dr. Scott Steele: Fantastic. What's your favorite sport either to watch or to play?

Dr. Arielle Kanters: Favorite sport to participate in is swimming. Not much playing, I guess, going on there. Watching, I love going to baseball games.

Dr. Scott Steele: Fantastic. Go Guardians. Favorite place that you've traveled to or maybe something that you have a bucket list that you want to go to.

Dr. Arielle Kanters: Well, I am very spoiled. My family and I actually - we just got back from Alaska, so this has been a long overdue family trip. We had an amazing time. We went to Denali National Park. We saw the glaciers. It was a once-in-a-lifetime, hopefully more than once-in-a-lifetime, experience. It was incredible. Highly recommend it.

Dr. Scott Steele: Yeah. I love Alaska. It's a beautiful place to go to. Then finally, you've been a lot of different places, traveled a lot. Tell us something that you like about living here in Northeast Ohio.

Dr. Arielle Kanters: I am one of the biggest Cleveland advocates you're going to meet. I think living here is amazing. I think we have incredible food. We have incredible cultural experiences. We have one of the largest theater districts in the country. When I was a medical student here, I had season tickets to Broadway shows. One of these days, I'm going to get back there, start it up again now that there are more opportunities for open theater, but there's just so much to do here. I love living here.

Dr. Scott Steele: Amen to that. Give us a final take-home message regarding colorectal cancer treatment to our patients and our listeners out there.

Dr. Arielle Kanters: You know what? I'm going to use an anecdote from a patient I was just talking to before I came down here. If you're concerned, talk to someone. If you feel like something's wrong and you're passing blood that you shouldn't be, don't let yourself write it off as hemorrhoids. Please don't let someone else write it off as hemorrhoids. Make sure you get checked out. We're seeing these scary rates in younger patients. And this isn't to scare anyone, it's just to trust your body. If you want to get checked out, please reach out. You want to make sure that you get seen by the right practitioner. As much as you maybe don't have to have a colonoscopy until you're 45 years old, but just because you're not 45 doesn't mean something can't happen. Take-home points: we can take care of you, we can cure your cancer, but please, when in doubt, get checked out so we can take care of it early.

Dr. Scott Steele: Yeah, absolutely. Again, for our listeners, we have been absolutely thrilled through a generous grant by the Edward DeBartolo Jr. Family for a young-onset center of excellence here at the Cleveland Clinic. Even if you're young, please check that out and you can find more on our website.

To download a colorectal cancer treatment guide, please visit clevelandclinic.org/coloncancerguide. That's clevelandclinic.org/coloncancerguide. To schedule a colonoscopy at the Cleveland Clinic, call Cleveland Clinic Digestive Disease and Surgery Institute at (216) 444-7000. That's (216) 444-7000. Dr. Kanters, thank you so much for joining us here on Butts and Guts.

Dr. Arielle Kanters: Thanks for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.