Hereditary Colon Cancer

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 again, 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. And today, I'm very pleased to have Dr. David Liska, who is one of our own. He's the Section Head of Colorectal Cancer Oncology. He's also the Director of the Weiss Center for Hereditary Colorectal Cancer Neoplasms, and he actually also leads our Young Onset Colorectal Cancer Center of Excellence. David is also our James Church and Edward DeBartolo, Jr. Family Endowed Chair. Welcome so much to Butts and Guts.

Dr. David Liska: Thanks so much for having me.

Dr. Scott Steele: So today we're going to talk about something near and dear to your heart, and that's hereditary colon cancer. But before we jump into that, 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 Cleveland Clinic?

Dr. David Liska: So, I was born in Vienna, Austria and then came here for college. I started off in Baltimore and then did my medical school in New Haven at Yale University. And then I did my residency in New York City, and then came for my fellowship to Cleveland. I didn't really know where Cleveland was on the map before I got here, but I found it and have stayed here ever since.

Dr. Scott Steele: And we are so lucky to have you here. And so today, as I said, we're going to talk a little bit about hereditary colon cancer. So, most people we've had here on Butts and Guts to discuss colon cancer, but can you touch on what it means if somebody has hereditary colon cancer and how is that different?

Dr. David Liska: Right. Hereditary colon cancer means that the person who has cancer got the cancer due to a genetic condition that they have. So, they inherited or developed a genetic condition that they can then pass on to their children, and that is the reason for the cancer that they have. So, it's an abnormality in their genome that is directly causing them to develop cancer. And usually, these people are younger when they develop cancer.

Dr. Scott Steele: So, is this common to have hereditary colorectal cancer just to get it spontaneously more common?

Dr. David Liska: Yeah, so hereditary colon cancer is quite rare. Among all colorectal cancers, probably only about five to maybe eight percent are due to hereditary condition. Again, in younger people of colorectal cancer, we find hereditary conditions to be more common. So, among young people, it can be somewhere between 15 to 20 percent, but still the vast majority of colorectal cancers are not due to hereditary conditions. It's pretty rare.

Dr. Scott Steele: So, is hereditary colorectal cancer one type? Are there multiple types? And if so, what are the common types?

Dr. David Liska: Yeah, there are many different types of colorectal cancer and that's because there are many different types of genes that can be responsible for causing colon cancer. The two most common ones are Lynch syndrome and FAP, which stands for familial adenomatous polyposis. And they both are characterized by developing colorectal cancer at a much higher risk and at a younger age, but they're quite different in how they present.

FAP is very characteristic by the fact that patients who have FAP develop hundreds to thousands of polyps in their colon, and each one of these polyps can then, in theory, turn into a cancer. And people who have the classical form of FAP - if you don't do anything about their polyps in the colon, almost a hundred percent will develop colorectal cancer.

Lynch syndrome on the other hand, usually these people don't develop that many polyps. They can develop some polyps, but usually they develop few polyps, and have a risk for colorectal cancer that is usually a little bit later in their life than what FAP patients have. And the risk is not a hundred percent, but still a lot higher than the average population.

Dr. Scott Steele: So, "truth or myth." Truth or myth: any family history of colon cancer or colorectal cancer increases someone's risk of developing cancer.

Dr. David Liska: Not entirely true. It is true for first degree relatives, especially. If you have a first degree relative with colorectal cancer, the risk for colorectal cancer in that person who has a first degree relative is significantly increased. So, the average risk for anyone in the population who doesn't have a relative is about five percent to develop colorectal cancer in their lifetime. If somebody has a first degree relative, and a first-degree relative means either your parents or your siblings or your children, then your risk can increase to somewhere between 15 to 20 percent.

If it's a second degree relative, that risk is not nearly as high. But the risk, if you have a first degree relative who developed colorectal cancer at a younger age, meaning younger than the age of 45, then the risk is even higher. So, if you have a family history, it can be very important especially if it's a first degree relative, and especially if that first degree relative had it at a young age.

Dr. Scott Steele: So, David, we talked about diagnosis of colorectal cancer in the past with colonoscopy and all the different tests that we have. But specifically, how does diagnosis work for the hereditary side of it?

Dr. David Liska: So, it has changed over the years. In the past when we didn't have such easy access to genetic testing, a lot of times the diagnosis was made based on the clinical phenotype, meaning how the syndrome is manifesting itself in the patients. So, in FAP, for example, where people develop hundreds to thousands of polyps, a lot of times the diagnosis would be made based on these manifestations. So, it's not just the polyps and FAP, there's certain characteristic findings in a person's eye and some other findings in a person with FAP that can help make the diagnosis. Nowadays, where we have such easy access to genetic testing and where we can relatively, in an easy and quick and cheap fashion, test multiple genes at the same time, in patients where we have a high suspicion that they have a genetic condition, we do what's called multi-gene panel testing, where we get either a blood sample or a saliva sample, and they can test 20 to 50 genes or even more at the same time to see if any of these genes is affected that would explain their hereditary colorectal cancer condition.

Dr. Scott Steele: So, what does treatment look like specifically for patients experiencing hereditary colon or hereditary colorectal cancer?

Dr. David Liska: So, that really depends on the type of hereditary condition the person has and also if they already have colon cancer or not. If a person is diagnosed with colon cancer and then is found out to have hereditary condition kind of at the same time, then number one, the most important thing is to treat the current cancer that they have developed. And that treatment follows usually similar guidelines that any colon cancer in somebody who's not hereditary has. But at the same time, when we treat someone with hereditary cancer, we are not only thinking about treating the current cancer, but also treating them in a fashion that would reduce the risk of developing another cancer in the future because they're at higher risk for that.

We also have to think not only about that specific cancer, but also about other potential cancers that that person is at a higher risk for. So, for example, if somebody with Lynch syndrome who develops a colon cancer, if that same colon cancer in a person without Lynch syndrome would require taking only a small part of the colon out, and a person with Lynch syndrome, we sometimes will take out a larger part of the colon to reduce the risk of developing another cancer in the remaining colon. Now every hereditary syndrome is a little bit different and sometimes that only recently we found out in Lynch syndrome specifically was that patients with Lynch syndrome can actually be treated with immunotherapy. So, that's a different type of chemotherapy that patients receive with colon cancer that have Lynch syndrome, and that has really revolutionized how we treat Lynch syndrome specifically.

There are other hereditary conditions such as FAP where we try to prevent even a cancer developing to begin with. So even a patient without cancer with FAP, because we know that almost a hundred percent of patients who would develop cancer, we sometimes do prophylactic surgery, or we almost always do prophylactic surgery, where we take out most of the colon or sometimes all of the colon to prevent cancer from developing.

Dr. Scott Steele: So, David, obviously we said earlier that you lead the Weiss Center that's specifically geared towards hereditary colorectal cancer neoplasms, and that dovetails nicely to your other leadership role in terms of leading our Young Onset Colorectal Cancer Center of Excellence, and combine those together, and you're also our Section Chief of Oncology. So, what treatment options specifically are offered here at the Weiss Center or under all of your hats that you wear at the Cleveland Clinic?

Dr. David Liska: Yeah, so like we discussed, hereditary colorectal cancer is a pretty rare condition. Only about five percent of colon cancers are due to hereditary disease. So, there isn't that much expertise available internationally or in the United States to take care of these conditions, which can be quite complicated. And they require multidisciplinary care, meaning it's not just a colorectal cancer surgeon you need, when you have a hereditary condition. You need input from gastroenterologists, oncologists, different types of surgeons depending on what their hereditary condition is.

So, it's really important for a person with a hereditary cancer condition to be treated at a center that has expertise in treating hereditary conditions and not only to have the expertise available but to have the option for coordinated care. It's not enough for a center to have many experts, but it's also important for that center to facilitate treatment of patients so that when a patient comes and needs to see five, six, seven different experts, that all that can be coordinated and be done in a fashion that makes it easy for the patient, and also that one specialty talks to the other and that everything is being done in a holistic fashion.

At the Weiss Center, our goal is really to provide comprehensive care for patients with hereditary colorectal cancer conditions to prevent colorectal cancer, prevent death from colorectal cancer, but at the same time focusing on maximizing the quality of life for that patient. So, we are very lucky to have experts who've been treating patients with colorectal conditions that are extremely rare but here in our center are common. So, we have developed expertise, and we have many experts from many different disciplines, and we all work together. We meet every week to discuss patients, and we have coordinators as part of our center. We have coordinators whose only job is to make sure that these patients are getting all the care they need and that they can come and have all the different appointments they need in an easy fashion. So, a patient can come in and within one day or two days, see multiple specialists have multiple different procedures done and then go back to where they came from without having to disrupt many months of their lives, which would happen if we don't coordinate their care.

Dr. Scott Steele: So, I'm a listener out there and I have a family history. Is there something that I can do to prevent the onset of colon cancer, and does it matter if I have the hereditary gene or I don't have the hereditary gene?

Dr. David Liska: Yeah, that's an extremely important question. And the number one thing is yes, colon cancer can be prevented regardless of if you have a family history or not. We have the ability to prevent colon cancer by doing a colonoscopy, finding pre-cancerous lesions and removing them, so we can actually prevent it stopping the cancer as we can watch it develop with a colonoscopy.

Now in hereditary conditions, the risk for cancer is higher, and sometimes colonoscopy itself, is not sufficient and we need to do other treatments such as prophylactic surgery. So that's why it's important when you have a family history to know exactly what that family history is and is it strong enough for the family history that would warrant genetic testing so that we can establish a hereditary condition. And if there is a hereditary condition, we can then again do all the different things we do at the Weiss Center to help prevent the cancer from happening.

Dr. Scott Steele: So, what actions should somebody take if they're unsure of their family medical history?

Dr. David Liska: Number one is talking to your family members. Thanksgiving time is always a good time when family gets around to talk. I know not everybody likes talking about colorectal cancer at Thanksgiving dinner. But, whenever your family gets around, if you know that there's a family history figuring out what exactly it was.

Now some people are not in contact with family members and it's hard to find out. Genetic testing is always a possibility. Like I said, it's gotten a lot cheaper. So even if you don't have a strong indication, and it's something you can discuss with a genetic counselor. If we have clues from a colonoscopy, let's say we do a colonoscopy in someone and there's more polyps than we would expect, even if we don't have a family history, sometimes just a number of polyps can be a clue towards a genetic condition that would then qualify for genetic testing, and then we can establish the diagnosis. So even if you don't know your family history exactly, sometimes if we have a high suspicion for genetic condition, we can do testing.

Dr. Scott Steele: So, you mentioned at the Weiss Center earlier about the treatments, but are there any advancements on the horizon when it comes to either diagnosis or treatment of hereditary colon cancer?

Dr. David Liska: Yeah, and that's another thing we are very passionate about at the Weiss Center, doing research on hereditary conditions. We see it as one of our main responsibilities because we take care of so many patients with hereditary conditions that are so rare. We are uniquely positioned to study these conditions and to come up with new treatments. So, we always have trials available that we are enrolling patients to. For Lynch syndrome, we have an immunotherapy trial. We have a vaccine trial going on for FAP. One of the, really, holy grails we're trying to find is medications that can help stop polyps from developing. So, we have trials in that realm, as well.

So, there's a lot of exciting research going on in hereditary colorectal cancer conditions that is being done at the Weiss Center. And there are new drugs, new treatments, new surgical techniques that become available all the time, and we are really proud that we are at the forefront of this.

Dr. Scott Steele: That's fantastic stuff. And so now, it's time to get to know you a little bit better with our quick hitters. So first of all, what is your favorite sport?

Dr. David Liska: So, I'm from Austria, so downhill skiing is one that I really enjoy. In terms of watching, I've been enjoying watching the NBA now with Cleveland being in the playoffs.

Dr. Scott Steele: What was your first car?

Dr. David Liska: A Jeep Wrangler.

Dr. Scott Steele: What is a place that you've either been to or on your bucket list that you want to go to?

Dr. David Liska: I would like to go to Australia.

Dr. Scott Steele: And finally, tell us something you like about living here in Northeast Ohio.

Dr. David Liska: People are just very nice here, and that's definitely what I appreciate the most about living here in Ohio.

Dr. Scott Steele: Absolutely. So, give us a final take home message on hereditary colorectal cancer.

Dr. David Liska: The final take home message is that colorectal cancer can be prevented regardless of if it's hereditary or sporadic, and knowing your family history is one important aspect of how to prevent that. So, find out your family history, and like we discussed, even if you're not completely sure about your family history, if there are enough clues that make us suspicious of a family history, it's something that can be diagnosed and then can be treated and prevented.

Dr. Scott Steele: That's fantastic advice. And so, to learn more about colon cancer or colorectal cancer diagnosis and treatment here at the Cleveland Clinic, especially regarding the Weiss Center and hereditary neoplasms, visit clevelandclinic.org/coloncancer. Again, that's clevelandclinic.org/coloncancer. You can also call our Cancer Answer Line at 866-223-8100. That's 866-223-8100. David, thanks so much for joining us here on Butts and Guts.

Dr. David Liska: Thanks so much for having me.

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