Evolving Strategies in CRC Care: Screening, Treatment, and Equity

ReachMD Announcer:
You’re listening to On the Frontlines of Colorectal Cancer on ReachMD. And now, here’s your host, Ryan Quigley.

Ryan:
This is On the Frontlines of Colorectal Cancer on ReachMD. I’m Ryan Quigley, and joining me to discuss the evolution of colorectal cancer management are Drs. Thomas Cataldo and Sowmya Sharma. Dr. Cataldo is the Program Director of Colorectal Surgery and an Assistant Professor of Surgery at Beth Israel Deaconess Medical Center.

Dr. Cataldo, welcome to the program. Thank you for doing this.

Dr. Cataldo:
Thank you for having me. 

Ryan:
Also joining us from Beth Israel Deaconess Medical Center is Dr. Sharma, who’s a colorectal surgery fellow.

Dr. Sharma, thank you as well for being here.

Dr. Sharma:
I’m very happy to be here. Thank you for having me.

Ryan:
So, let’s dive right in. And, Dr. Cataldo, this question is for you. When we look back at the 20th century, what were some of the major breakthroughs in colorectal cancer?

Dr. Cataldo:
Not to be too silly about it, but the invention of general anesthesia and the continuous improvements, the invention of antibiotics, which we could never do anything without, and then surgical techniques haven’t really changed throughout the entire 20th century. But then, we invented things like chemotherapy, and now we have immunotherapy and the discovery of the therapeutic value of well-controlled radiation. And last is changes in surgical techniques—that includes things like laparoscopy and robotics. And now, we even have some very advanced robotic platforms that are more 21st century.

Ryan:
Thank you for that. And so, Dr. Sharma, turning to you now, when did colorectal cancer screening become a public health priority, and what drove that shift?

Dr. Sharma:
So, I think the onset of it becoming a public health priority was sometime in the late 1990s, when we started to understand a little bit what the progression of colorectal cancer was and that it’s not only detectable—it’s also preventable. It progresses over about 10 years from starting off as normal mucosa to cancer, and it slowly shifted from whether we should screen people to, how do we get more people to screen? And what are the different ways we can screen people? And now, it’s shifting to even bringing down the age that we start screening people, just because the incidence of colorectal cancer in younger people is increasing, even though screening has reduced the incidence in the older populations.

Ryan:
Now, Dr. Cataldo, Dr. Sharma just alluded to how the incidence of colorectal cancer is increasing in younger people over time, which, of course, indicates something of an evolution going on here. How has our approach to treating patients with colorectal cancer evolved over time?

Dr. Cataldo:
So, what we’ve actually seen is kind of weird. There are two populations. There is the population of folks who, normally, if they were never screened and never got any intervention, would all start getting colon cancer in their 50s and 60s and start dying in their 70s. That population has actually decreased remarkably with the use of proper colorectal cancer screening and the removing of adenomatous polyps before they turn into cancer. If you look at the overall rate of colon cancer, it’s going down.

What Dr. Sharma alluded to is there is an entirely different population of young people. And when I talk about young, we’re talking starting in their 20s through their early 40s—a different population of colon cancer. It’s still colon cancer, but it’s far more oriented towards the very end of the colon. It has certain genetic qualities that previous colorectal cancer doesn’t have. And so it’s the same disease in a new way, and we really don’t understand why this population is exploding. But there’s a lot of very smart people working on it. It changes our screening a little bit, but other than that, the overall rate really is decreasing.

Ryan:
For those just tuning in, you’re listening to On the Frontlines of Colorectal Cancer on ReachMD. I’m Ryan Quigley, and I’m speaking with Drs. Thomas Cataldo and Sowmya Sharma about the past, present and future of colorectal cancer care.

So, Dr. Sharma, back to you now—how have disparities in colorectal cancer outcomes evolved, and what’s being done to close those gaps?

Dr. Sharma:
I think, historically, we’ve looked at disparities in three big groups, one being racial disparities, another being income-related disparities, and the third being rural versus urban—where you’re living. Initially, for a large part of these disparities, they found that these groups were more likely to be diagnosed later and more likely to have mortality from colorectal cancer, and for a long time, this was thought to be related to the biology of the cancer itself. But what we now understand is a large part of that is access which is a big driver of that disparity.

When you equalize for screening and follow-up treatment, the outcomes are the same, and this just tells us that the disparities are more structural and not inherent. But we have seen progress in recent years. There’s more organizing screening programs. How we screen is changing. Not everybody needs to get a colonoscopy. There’s other tests that we can provide for people who don’t have the same access. The focus has really been shifting to promoting screening as much as possible and helping remove financial barriers and outreach.

I think looking at the differences in our outcomes is very important. I know we do that at BI. We have a special clinic for specific groups where we notice that the outcomes are worse for to be able to equalize that care.

Ryan:
Dr. Cataldo, how has the introduction of population-level data and cancer registries influenced our understanding of colorectal cancer trends?

Dr. Cataldo:
The biggest thing—it’s not necessarily a cancer registry—is the NSQIP, the National Surgical Quality database that grew out of the VA, and that really looked at the quality of surgery that’s being done and making sure that surgery—for colon cancer, as an example—is being done by people who are focused on colon cancer and not general surgeons. So, modifying and looking at experience and volume and high-volume centers is probably the first thing that drove the quality of surgical care for colorectal cancer. The large databases are valuable for looking at trends and interventions. In a weird way, they’re great for population information, but they don’t necessarily impact what we do.

There are some very huge multidisciplinary, multi-institutional, and sometimes, multinational studies that are performed that allow us to compare things like chemotherapy and radiation therapy over large populations, and that really is the biggest impact on how we manage colorectal cancer.

Ryan:
And now, before we wrap up this program—Dr. Sharma, this is for you—where do you see the future of colorectal cancer care headed in the next few years?

Dr. Sharma:
It’s a really exciting time to be a colorectal surgeon right now. A lot of things are changing. I think the future is heading towards making patient care more personalized. There’s a huge focus on organ preservation, particularly in rectal cancer, where we’re doing chemo and radiation before surgery. We found that sometimes patients end up not needing surgery, and we’re just picking the right patients who fit into that group.

When you talk about personalized medications and immunotherapies, understanding tumor biology better to be able to treat certain tumors that immunotherapy would be appropriate for. And then I know that we’re looking at the rise of blood-based biomarkers. There’s a lot of things happening that make it a really exciting time to be a colorectal surgeon. 

Ryan:
And that’s a great comment for us to think on as we come to the end of today’s program. And I want to thank my guests, Dr. Thomas Cataldo and Dr. Sowmya Sharma, for joining me to explore how our approach to colorectal cancer has changed over the last decade.

Dr. Cataldo, Dr. Sharma, it was wonderful having you on the program today.

Dr. Cataldo:
Thanks. It’s been my pleasure.

Dr. Sharma:
Thanks for having me. This was great.

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