Information Session: Colorectal Cancer and Digestive Health

Corporate Speakers

• Diane Reidy-Lagunes; Memorial Sloan Kettering Cancer Center; Oncologist and Associate Deputy Physician-in-Chief, Regional Care Network;
• Robin Mendelsohn; Memorial Sloan Kettering Cancer Center; Gastroenterologist
• J. Joshua Smith; Memorial Sloan Kettering Cancer Center; Colorectal Surgeon
• Paul Romesser; Memorial Sloan Kettering Cancer Center; Radiation Oncologist
• Andrea Cercek; Memorial Sloan Kettering Cancer Center; Medical Oncologist
• Joe Bacani; Memorial Sloan Kettering Cancer Center; Solid Tumor-Gastrointestinal Medical Oncology

 

Diane Reidy-Lagunes: Welcome to this MSK Information Session where this afternoon we'll talk about colorectal cancer and general digestive health.  As you heard, I'm Diane Reidy-Lagunes, and I am a medical oncologist who cares for patients with colorectal cancer.

Thank you to the hundreds of you who have joined our call today.  I want you to know that MSK is working hard to keep you and your loved ones safe when you come for an appointment or treatment at any one of our locations.  We understand that you may be feeling particularly vulnerable during this time. 

Together with our panel of experts, we’ll also answer some of the many questions you shared with us in advance of this call.  We will try to get to as many of those questions that you sent in as possible during our time together.  And I want to remind you that you that MSK doctors and care teams are ready and willing to talk to you directly about any of your concerns.  I encourage you to reach out to them and discuss the next steps in your care, and to ask them any questions that don't get answered today.

I want to start by talking a little bit about what you would expect when you come to MSK, some of you may have done that already, but for an appointment or treatment.  And as many of you know, we have put in place many new policies and procedures to address the unfortunate unique challenges that were brought on by COVID-19.

First, we're screening all patients and staff or COVID-19 symptoms before they enter MSK clinical locations.  So on the day before your appointment or treatment, your doctor's assistant will call you and ask questions about how you're feeling.  And those questions would include checking your temperature.  And if you have any flu- or cold-like symptoms, fever, cough or difficulty breathing, your doctor will arrange for testing for COVID-19.

On the day you present to the clinic, just to be extra cautious and safe, those same questions will be asked.  Again, if you screen positive for those symptoms, we will offer testing right there immediately and you will be swabbed.  After you’re swabbed, you will be asked to return home until those tests are resulted.  If you have no symptoms, you will proceed to your appointment. 

We have made the difficult decision to not allow patients to have visitors or bring people with them to appointments with few exceptions.  We're also providing all patients and staff with masks upon arrival, and they are required to wear those masks at all times to cleat both our clinicians as well as our patients safe.

You'll also notice that we've increased how often we clean high-contact surfaces and have hand sanitizers available at many different entrances, elevators, and other frequently visited locations.  And we've taken steps to ensure social distancing, removing furniture to maintain safe distances of at least six feet apart.

And lastly, you'll hear a lot about our telemedicine services so that many people appointments with healthcare providers can be done without an in-person visit. 

Diane Reidy-Lagunes: So I'd like to start by asking Robin that, Robin, many of our listeners asked if they should be coming in for screenings during this time.  You are a gastroenterologist here at MSK.  Can you talk to us a little bit why it's so important to stay on top of routine screening and other scheduled appointments?

Questions and Answers  

Robin Mendelsohn: Thanks, Diane.  Yes, this is really such an important point.  So colon cancer screening has shown to significantly decrease not only the rates of colon cancer but also deaths from colon cancer.  So screening definitely should not be ignored.

Obviously, it's always important to discuss this with your doctor the risks and benefits of undergoing screening.  And I think there are a few important points to consider during this time.

So, first, it really depends whether this is your first colonoscopy or a follow up colonoscopy.  Both shouldn't be ignored.  But it's really been shown that the first one is actually the most important one.  So if you're in the age group for screening, which generally is 50 and over, please discuss this with your doctor.

Second, I think it's important to note that right now COVID rates in New York City are on the lower side.  So this may be a great window to use this opportunity to get screened.

And lastly, though many of us consider colonoscopy to be the gold standard for colon cancer screening, the best test is really the one that gets done.  And there are actually some stool tests that you can do in your own home.  So if you are nervous about coming in, you should really discuss all of these options with your physician.

Diane Reidy-Lagunes: I think that point on, you know, COVID numbers, as you said, have gone down, and so it's so critical to really focus on our own health and care and do that screening now because unfortunately don't know what's to come.  So I think that emphasis is really important.

Robin Mendelsohn: Absolutely.

Diane Reidy-Lagunes: I'm going to bring on our surgical oncologist, Dr. Josh Smith, to talk about how we are keeping our patients safe in the operating room and post surgery.  Josh, can you talk a little bit about the procedures that are taking place around patients that have to undergo surgery?

J. Joshua Smith: Sure, sure.  Thanks, Diane.  So, you know, it's really important to understand (inaudible) one of the safest places to be that we have instituted a procedure where if there are patients who have COVID, they are taken to a dedicated COVID OR.  And in addition to that, of course, there's always the standard use of universal precautions for every patient.

But there is also now routine screening of all patients who come to the OR for COVID.  Prior to coming to the OR, this was previously two days before any invasive procedure in the operating room; now it's three days before.  In addition, as has been previously mentioned, there now visitation restrictions based on the patient themselves.  In any unique scenarios, we have limited that to one person that can visit the patient in the hospital.

In addition, as has also been alluded to, there's strict surveillance of faculty and staff.  And, of course, in the OR, we have always used personal protective equipment.  But now this has been done maximally, especially at the start of the procedure, because we know COVID is spread mainly from respiratory scenarios.  So when the patient undergoes anesthesia, people leave the room and the anesthesiologist have maximal personal protective equipment, and then try and just minimize exposure for both the patient and the providers.  So I think from the time before the patient comes to home OR to after they leave the OR and when they're in recovery, there's significant protection for both the patients and the providers and the hospital at MSK.

Diane Reidy-Lagunes: Thank you, Josh.  Yes, I think the fact that we now have testing so widely available for our staff and that we're doing that routinely every couple of days is also so important and can be very helpful.

J. Joshua Smith: Yes.

Diane Reidy-Lagunes: We've specifically got some questions about upcoming radiation appointments.  And I'd like to bring in Dr. Paul Romesser, Radiation Oncologist, here to address the importance of continuing these appointments.  Paul, can you talk to us a little bit about that?

Paul Romesser: Yes, great.  Thanks, Diane.  This is a question that many patients are asking us.  And, first, I do want to highlight that similar to the institute and to all the departments, the radiation oncology department has really taken multiple steps to ensure safety of patients coming in for radiation during this challenging and stressful time.  So similar way you heard about, we're doing routine testing of all patients undergoing treatment, spacing out appointments to ensure social distancing and really kind of working together with telehealth and whatnot to ensure that we have patient access.  And it's really important to discuss with your radiation oncologist the benefits of the radiation and the timing of treatment especially because oftentimes radiation is a daily process over the course of a couple of weeks. 

I think one real important point to note is that once you start radiation, it's really important to adhere to the treatment schedule.  And the reason for this is because any breaks in treatment can really lower the chance of tumor eradication.  And we've taken opportunities now to kind of look at our radiation treatment paradigms and really to incorporate really effective treatments that minimize the amount of time spent in the hospital, which translates to less time commuting, less risk of exposure during these stressful times.  And in fact, we’ve recently published our recommendations, not only for colorectal, but also for other disease sites to really allow other centers around the country to follow our lead.

Diane Reidy-Lagunes: Yes, I think that's a really important point, Paul, that many of us were trying our best during these difficult times to think about what's the appropriate treatments and can we think about modifying treatments changing, for example, from IVs to oral when feasible, and like you said, sort of leading the efforts to think about what types of radiation and timing and intervals.  So thank you for leading those efforts.

At MSK, we have seen a lot of changes, some of which, again, for example, were changes in the way that we were delivering some of these therapies.  But telemedicine is here to stay.  And certainly the way that we care for patients is different.

So I'd like to introduce Dr. Andrea Cercek, who's a medical oncologist who specializes on colorectal cancer, to talk to us a little bit about what it's like for these telemedicine options for our patients.  Andrea, can you talk a little bit about that?

Andrea Cercek: Yes, sure.  Thanks, Diane.  So as you said, telemedicine is here to stay.  It's actually been around for a really long time.  And essentially, it's the use of technology, which enables remote care.  So basically it enables physicians or care providers to treat patients wherever needed, wherever needed from their home, using either a computer or smartphone. 

So there's a few different platforms that can be used to ensure patient safety.  We have two at MSK that we're most commonly using now, either Doximity or Jabber.  And effectively, it's a video conference.  It's almost like a FaceTime call that has replaced a clinic visit.  And this was obviously critically important for us in the early months, weeks or months of COVID, when, really, we were all quarantining and working from home, and our patients were at home.  And we were able to connect with a patient, check on the patient, you know, do a clinical review, even do a limited physical exam, if something was of concern via the video connection, and then make an important clinical decision as to whether or not they need treatments, they need more serious intervention or if we can continue to care from home.

And so in many ways, it's also been very helpful for some of our second opinions or patients that come from very far that are not able to travel particularly now, but even I think in the future, where we can connect and do a full second opinion, face-to-face with the patient, just remotely via video.

So in a -- it will definitely be here to stay.  I think in some capacity, we are opening our clinics back up, as everyone has mentioned, with very careful screening as you nicely described in our clinics as well.  But I think for many patients, this will still be an important part of their routine clinical care.

Diane Reidy-Lagunes: Yes, I think you're absolutely right, particularly since we had to make the difficult decision of not allowing visitors into the clinic for the safety of our patients.  It's a really nice opportunity to allow the whole family to participate in the clinic visit by doing it virtually and we get to meet kids and grandkids and dogs and other people who pop up which is really nice.  I mean, obviously the virtual hugs are not the same, but I think it is an important part of care during this difficult time.  And certainly for those patients that do require visits, we are also here with appropriate PPE as you said to see those people in clinic.

It can be --

J. Joshua Smith: Diane, can I say one --

Diane Reidy-Lagunes: Yes, please, Josh.

(Multiple speakers)

J. Joshua Smith: -- each different to the patient post surgically to be able to do telemedicine.  I think it saves people a lot of time and energy coming back in for post-op visits.  And doing that via Doximity or some of the approved ways that we can do video follow-ups has really I think transformed the way that we can contact and follow up patients.  And it's been, I think, really helpful for the surgical patients in reducing the stress and having to come back in to the city and other ways that it's made us I think become very creative in the ways that we follow up patients post surgically.  And I think it's really been transformative and helpful in the way that we will do post-op care going forward.

Diane Reidy-Lagunes: That's great.  And even if financial burden, I mean, we all recognize that the cost of parking in New York City and other things can be a lot on a patient.  So I totally agree.  And our patients are getting very good at pushing on their belly and doing their own physical exam so that we can understand how they're doing.

But it is a difficult time, as you said, regardless of COVID-19.  So I'd like to ask one of our wonderful nurses, Joe Bacani, who's here with us today to share some of the support services that we have to offer for our patients.  Joe, can talk a little bit about that?

Joe Bacani: Sure, thank you, Diane.  So, I mean, regardless of COVID diagnosis of colorectal cancer is difficult in and of itself.  And, you know, patients come, they meet their oncologist, they get their treatment plan, and then they move forward.  Sometimes what we can tend to forget is that they have a life outside of upcoming for their treatments.  And to help support that life and somewhat of a normalcy of life, we have a lot of supportive services here at MSK, being the Comprehensive Center that we have.  We're here to take care of our patients physically as well as mentally and like you said, Diane, financially.

So, with that being said, we have services such as our Social Work Department and Case Management to help with any at home needs, particularly for the for the patient but also for the family in some instances.  You know, when we treat the patient, we treat the patient as a whole, so meaning their family and close loved ones.

We also -- for those who have very strong spiritual health, we have chaplaincy services.  For our younger population, we have fertility.  We have integrative medicine for any kind of new up and coming non-traditional ways to treat either symptoms or for diagnosis.  We also have things like smoking cessation and lactation consultants.  So a lot of ancillary services to kind of not only take care of the patient, the patient's cancer, but to take care of their other aspects of their life because we have to remember that although they are patient, they're also human beings.  They have a lot going on outside of the four walls of MSK.

So the good thing is we screen them regularly to see if anyone's appropriate.  The nurses here are wonderful at approaching patients and offering these services up.  And the good thing is with these services, if there's resistance from patients, for example, like with smoking cessation, the department and the people that are trained to kind of deal with that resistance but still leave the conversation so that they let them know that they're available.  They're here, you know, we're here to help, and the doors never close.

Diane Reidy-Lagunes: Absolutely.  Dr. Mendelsohn, the number one question we received today from our listeners is on the topic of nutrition and recommended diet.  Can you share some guidance around nutrition for those who have undergone treatment for colorectal cancer?

Robin Mendelsohn: Yes, so this is a great topic.  So, you know, I think the first thing to note is that obesity in and of itself has been shown to be one of the biggest risk factors for colon cancer.  So being a normal weight is so important.  Beyond that, there are some data showing that red and processed meats are associated with an increased risk of colon cancer.  So limiting these foods are helpful.  And overall, what we really recommend is a plant-based diet, which that doesn't mean that you have to be vegetarian or have to be vegan.  What it really means is that two-thirds or more of your plate should be filled with fruits, vegetables, whole grains and beans.  And one third or less should be animal protein.

Diane Reidy-Lagunes: Got it.  You've taught me before, what about probiotics?  I mean, are they are a supplement for the greens and the beans?

Robin Mendelsohn: Yes, so probiotics is always such a hot topic.  And this has been looked at.  And overall, for general GI health, there actually doesn't seem to be a beneficial effect for probiotics.  But that being said, there are some specific diseases where they have been found to be beneficial.  So it's always good to have a discussion with your doctor to see if this fits for you.  But, overall, it's not routinely recommended for GI health.

Diane Reidy-Lagunes: Okay.  Are there any sort of "bad foods" for those that are high risk for colorectal cancer that they really should stay away from?

Robin Mendelsohn: Yes, so I think the biggest one is really the red and processed meats, really staying away from that.  But, you know, obviously not completely.  And, you know, a little bit here and there is okay.  But really trying to avoid, the red and processed meats are really the big category.

Diane Reidy-Lagunes: Got it.  Josh, some of our listeners who are at high risk for colorectal cancer wrote in to ask what symptoms specifically should they be mindful of, what should people be watching out for, if they've had a history of colon cancer or at high risk for developing?

J. Joshua Smith: Yes, this is a great question.  And something we hear about a lot.  And I think that things that should signal a call to the doctor are nausea, abdominal fullness, pain, or bloating; I mean things that are abnormal and that are persistent.  Clearly changes in the stool caliber or the color in stool or if there's clearly blood in the stool or blood on the toilet paper after you move your bowels.  These are concerning things.  And certainly unintentional weight loss or somebody that's noticing persistent fatigue are things that are of concern and as I mentioned should signal a call to the person's physician so that this can be further evaluated and worked up because I think what we sometimes see especially in patients with rectal cancers are people attribute hemorrhoids, you know, or hemorrhoidal bleeding to or attribute bleeding to hemorrhoids, and they turned out that they have, you know, an anal cancer or rectal cancer.  And so, you know, bleeding especially is something that should be evaluated very quickly and is of concern.

Diane Reidy-Lagunes: Yes, and I think many of us are worried that people may have had those symptoms during the COVID crisis and just sort of blew it off because they were afraid to let anyone know.  So, again, just the importance of emphasizing if you have those symptoms to get checked out.

There was a listener who asked, why are so many young people diagnosed with colorectal cancer?  And at MSK we have a center dedicated to treating these young onset patients.  In fact, Dr. Mendelsohn and Cercek created that center.

So, Robin, can you talk to us a little bit about the center, why it's so important for younger people and to be mindful of the symptoms that Josh just mentioned, and what the latest research is on that front and what you're all been working on?

Robin Mendelsohn: Sure.  So, you know, the question, why are so many young people diagnosed with colorectal cancer is such an important question.  And I really wish we knew the answer.  But right now, we really don't know why this is happening.  But we opened the center for young onset colorectal cancer in March of 2018 not only to provide coordinated care to these young patients, but also to really try to figure out why this is happening.  So we can try to focus on prevention.

You know, until then, as Josh spoke about, it's really important to be mindful of symptoms.  And we looked at our patients here at MSK, and we found that the majority of younger patients are presenting with rectal bleeding.  And they also present with the other symptoms that Josh went over.  But the majority really present with rectal bleeding, so if you have ongoing symptoms, it's really, really important to discuss this so you can get a prompt workup.  I think it's important to reassure you that the majority of younger patients with rectal bleeding will not have cancer.  But it is definitely important to get this checked out so that it can be taken care of. 

Andrea, do you have anything to add?

Andrea Cercek: Yes, I mean, I'll just, you know, reiterate what you said.  I think the key here is that this is really a unique population of young adults where, you know, previously, we're used to colorectal cancer in patients in their 60s and 70s.  And so, there are really certain unique challenges to people in their 30s and 40s starting their life and regarding fertility, family planning, and so these are all services that existed MSK.  But as Robin mentioned, in terms of coordinated care, this is something that we focus on via the center for our young patients with colorectal cancer.  So support services like fertility, sexual health, psychology, psychiatry, and social work support in terms of important life decisions as well during this time from diagnosis, through treatment, and then into survivorship.

And then the second goal of the center, as Robin mentioned, is to really try to figure out why this is happening.  And, and one of the big questions in the research community that we don't quite know the answer to, but we think we're getting there, is this actually a completely different disease.  In other words, if there's -- is this something new that's happening and people in their 30s and 40s that's actually different in terms of how it starts to what the genetics of the tumor looked like, or what the molecular underpinnings are?  Or is it exactly the same disease that it has been occurring, you know, for a very long time in patients that are older in their 60s and 70s, where we believe we know why it's occurring?  Because the colon is aging and there are certain changes and mistakes, if you will, that lead to cancer in aging colons.  And this is why this was a disease of patients in their 60s and 70s.

So the key question really is, is this the same disease or not?  And most -- we believe, based on some of the research that's come out of our center, that this is really not a different disease, but rather really the same disease just happening much younger.  And so the key now is just hone in on that and really try to figure out why, who are these individuals at risk, as Robin mentioned, and then really focus on prevention in this specific subgroup.

So those are just some of the research questions that we're actively working on.  And it's actually a worldwide phenomenon.  So this is not something that's unique to New York or the East Coast or the United States.  Really, it's happening worldwide.

Diane Reidy-Lagunes: So fascinating.  So same genetic types of problems that you're seeing 30 years earlier, but we just don't know why.  But that is critical, right?  Because you would think that if you're younger, maybe it's just a totally different reason. 

But that's super helpful.  Obviously, research is such a big part of the Young Onset Center.  Talk to us a little bit about clinical trials, Andrea, particularly in this COVID setting.  Are we open for that?  And how does someone get into a clinical trial and when they're a patient at MSK?

Andrea Cercek: Yes, so that's a really important question because also it's a critical part of patient care with colorectal cancer, particularly, but not limited to patients with advanced disease. 

So in terms of COVID, initially, when there was a broad lockdown, we did close our early phase trials.  So clinical trials are -- there's a range of trials in terms of early phase two to later phase like third phase three trials where we know what the drug is and we know that it works.  And we're trying to show that it's better than some other treatment that's been done or a placebo.  And then early phase trials are trials where we have a drug, we believe that it works based on data in the lab, maybe data on mice, and now we're trying to see what is the safe dose and how well it works in patients. 

And so those trials were really the ones that were closed for a period of time, really across the country, at all major academic centers because of COVID.  And the reason they were closed is because we didn't know the efficacy we're testing.  The primary question is what's the safe dose?  It required a lot of visits, a lot of time spent at Memorial, getting blood work to see how the drug might work. 

So there was a lot of logistical things that come into play in these early phase trials, which is why they were briefly stopped for about a period of two months.  We have now opened up those trials as well, as well as some of our later phased studies that were ongoing even throughout COVID.  So now we're fully operational.  New trials are opening back up again.  So that's an important thing to keep in mind just because I know that a lot of patients were probably told for a period of time, especially in April and May that most trials were on hold.

So that being said, now with trials being open, the way that we make a decision, it is on an individual basis, depending on a number of factors.  Most importantly is, is the patient fit enough for an experimental therapy?  Because we don't know again what the efficacy will be.  And so is it the right thing to put someone through a trial and all the requirements in terms of the time and the effort and the energy that it comes to the meeting, to the appointments to receive the treatment.  Is that something that's actually of potential benefit to the patient? 

Some patients that may not be fit, after having multiple lines of chemotherapy may opt not to undergo a trial.  But if one is fit, then what we think about is, what exactly is their disease?  Where is their disease?  And we really, really look at now molecular markers, or what are genetic changes, changes that are unique to the tumor that we might be able to target?  You might have read about precision medicine, that's what this is where we're precisely targeting a specific change mutation or alteration in the tumor with a drug where we believe based on earlier data, the either preclinical as I mentioned, in the lab or mice, or in earlier studies in patients might work on this in this particular mutation.

So we look at that very carefully in choosing and then of course, the important discussion is always with the patient.  What are the risks and benefits, how time consuming this is?  I often tell the patients some of these studies are almost like a job, you really have to come and be present often.  And so it's always a discussion with the patient.  If that is something that they're interested in, then we look at the tumor itself and to see if there's any specific changes that we might be able to target with the trial. 

Many patients are interested in immunotherapy.  We have a number of immunotherapy studies.  And those of course make a difference also, depending on the on the actual genetics of the individual patient's tumor.

Diane Reidy-Lagunes: Absolutely.  Thank you.  Joe, setting gears a little bit, many of our patients ask, you know, they have a history of colon cancer and they're worried about the cancer returning or recurrence.  And so a common question is, what else can I do?  Sometimes we recommend and give chemotherapy but other dietary and lifestyle changes that a patient can sort of do to decrease the chances of the cancer coming back?

Joe Bacani: I think Dr. Mendelsohn kind of nailed it in regards to diet.  You know, there's clearly health benefits to eating well, in respects to colorectal cancers kind of limiting those foods that could potentially increase your risk like she said with the red processed meats trying to make sure you get your grains in, your vegetables, your fruits.  So eating a healthy diet is certainly important.

You know, every once in a while you're going to want to indulge but things in moderation. 

Diane Reidy-Lagunes: Absolutely.

Joe Bacani: I think being active there's also good research out this that suggests being active regular physical activity is good for patients actually who are on active treatment and for those who are thinking about recurrence.  When we say being active, you know, we don't you power lifting, running marathons but just being out and about and on your feet and kind of couch potato.

Diane Reidy-Lagunes: And Robin, what about vegan meats that seems to be hot nowadays.  I mean, is that an alternative that's worth pursuing as opposed to red meat?

Robin Mendelsohn: Yes, so, you know, it's -- like I said, it's important to have, you know, your balanced diet where, you know, a third or less should really be animal protein.  And if you want to substitute that with, you know, vegan protein, that's totally reasonable.  You just want to, you know, really -- as I, you know, I can't iterate enough what I said, you know, obesity plays a huge role.  And you really want to make sure that you're eating as healthy as you possibly can and obviously, enjoying you've been, you know, through a lot already.  But, you know, you want to stop smoking and limit alcohol intake.

And the other thing is that if you do have a reoccurrence, you really want to make sure that you're in the best shape to tolerate whatever treatment is necessary.  So you want to make sure you're as healthy as possible.  So adhering to the plant based diet and exercising is really key.

Diane Reidy-Lagunes: Yes, I totally agree.  And actually Lee Jones, who does research on Exercise Physiology, has done really beautiful work to show that patients undergoing chemotherapy, you know, there may be better delivery of the chemo when you're working out regularly with aerobic exercise.  And we certainly have data that show that people that do work out regularly and do aerobic exercise for three times a week or more do have a significant decrease in the cancer coming back.  Now that may be what we call selection bias, but it's very powerful, it's high 50 percent decrease in the chances of coming back.  So we definitely want our patients to get out move.

Paul, one listener asked once a growth has been dissolved by chemo radiation, how long after being asymptomatic?  Do you need to continue seeing a doctor?  How long do we -- and my patients always say I love you but I really don't want to see you?  When do they get to graduate and ring that bell that you guys have in radiation oncology?

Paul Romesser: Exactly.  This is a really common question.  Well, they -- the patient is going to ring the bell right when they finish treatment because we really want to celebrate that journey that they went through.  But right after they ring it, they come back and they say, how long do I have to continue to see you?  I don't want, you know, I want to get my life back.

And essentially, you know, each tumor, each scenario can be a little bit different.  But on average, it's for at least five years that patients need to continue to come in and be followed closely by us here at Memorial.  And it's, you know, it's important to say that even if you're feeling well, or the patient's feeling well, that they continue to come in for routine evaluations to really ensure that both the tumors not coming back.

And I think Josh went over some of those symptoms, but also to monitor, you know, are there any later unexpected side effects from treatment, and with close monitoring, if the tumor comes back nor we have a much greater chance of successful intervention than in patients who decline or, or kind of disappear on us.  So I think it's really important to kind of take this moment and stress that the follow up afterward is critical.

Now here we do try to make it easy on patients.  We talked about the telehealth earlier.  So sometimes if we're checking in to see, hey, how are you feeling?  Are you having any side effects?  Some of that can be done easily through telehealth.  But other times we need to bring patients in to actually do an exam.  And we kind of alternate between, you know, medical oncologist, radiation oncologist and surgical oncologists so that the patients are seeing the appropriate doctor at the appropriate time, but not coming in for unnecessary duplicate doctor visits because we know how important everyone's time is. 

Today, a lot of the work that we do here actually comes after a patient's complete the treatment really to ensure that we're guiding everyone back to that functional active lifestyle that we want to get back to.

Diane Reidy-Lagunes: Absolutely.  And along those lines, Paul, how long does it take a listener asked?  How long does it take for the body to truly recover after radiation therapy for example?  And are there times where radiation damage can actually be permanent?

Paul Romesser: Yes, that's a good question.  And I think a lot of this should absolutely be discussed.  And this is a great things to bring up in that initial visit with the radiation oncologist.  And I know here that we always talk about the immediate side effects that happened during or shortly after treatment, and potential late side effects.  And it's, you know, the immediate side effects really peak about one week after treatment.  And about four weeks after treatment, most patients feel about 80 or 90 percent recovered.  And that last little bit of recovery can take an additional couple weeks.

But it is important to note that our can have long term side effects.  And some of these side effects can be permanent.  So it's really something that as radiation oncologist, I want my patients to understand before we start radiation, and that's part of why follow up is so important.  It's because we want to be proactive with our patients to try to prevent these from happening.

And again, we've already heard about some of our team here at Memorial who helped us with that.  We've heard about the sexual health which we have for both men and women, the physical and occupational therapists that we work with, and even our rehabilitation doctors here and these are all really specialized individuals who work with cancer patients and specifically have expertise in working with patients who had pelvic radiation. 

So here, you know, our care doesn't stop with a cancer, we want to help really get that quality of life back.  That's why we're doing all that we do.

Diane Reidy-Lagunes: Absolutely, Paul.  And Andrea, for our patients where the cancer had spread, and we can't make it go away.  And so, you know, everything that we do for them is to keep them with us for as long as possible and to maintain their quality of life.  And some of our dearest patients, I think are on the phone right now that have been on chemotherapy for a really long time.  And so many of my patients will say like, how could this be healthy for me to really be on chemo this long?

So, can you talk about how chemotherapy might affect the body and our other organs?  Is it safe to do this for as long as we do it?  And could there be long term consequences about that when you're on chemo sometimes for years?

Andrea Cercek: Yes, absolutely.  I mean, I think it's an important question.  And it's one that comes up a lot, right?  Because we want to make sure that not only are we helping our patients, by having them live longer, but also maintaining quality of life and making sure that they are not suffering too many consequences because of the chemotherapy.

So the way I always describe it, and the way I think about it is chemotherapies are the broad cytotoxic drugs that we have the ones that we give intravenously.  Attack cells that are quickly dividing, so they cause typically temporary harm to things like the lining of the mouth, the lining of the intestinal tract, that's why people get mouth sores or diarrhea, the white cells, those are cells that are infection fighting cells that are normally very quickly dividing in the body.  So those are the ones that can be affected by chemotherapy.

Over time, chemotherapy can infect other blood cell lines as well like platelets and red cells like hemoglobin and cause anemia, because those cells also can -- are dividing quite quickly.  And so those are the things that are important to watch out for.

In terms of the organs, the liver is one our liver is kind of responsible for the processing of most of the chemotherapy, not all of the drugs, some of them the kidneys process, but once they go through the liver, we do see over time that there can be stress on the liver and it can turn into almost like a fatty liver, from just the stress of having to process so much chemotherapy.  So those are all really important things that we have to keep an eye on.  And they're not -- it's not the same for every patient.  It really depends on how the patients, individual -- organism, individual body, actually process of the drugs and what happens in terms of the toxicity.

But many of our patients, as you mentioned, thankfully actually can be on chemotherapy for a very long time.  Sometimes we need to take a break because of some of this physical aspects because of the diarrhea, because of the mouth sores, sometimes even just for emotional reasons because they can't face being connected to a bottle which most of our chemotherapies end up utilizing --

Diane Reidy-Lagunes: Or they hate the bottle.

Andrea Cercek: (Inaudible) as a bottle, you know, for a long time.  So we often have to take breaks for that reason.  But for the most part, most of the damage is reversible. 

The fatigue, I think, is something that can last for a long time and really affects most people.  And then the other big one that is often not reversible, but we are really mindful about and try to limit it is nerve damage from oxaliplatin and that’s used and most of our patients end up getting some type of exposure to oxaliplatin.  And so that's one that we tried not to treat patients with for too long and are very mindful of the possibility of the numbness and tingling that can happen in the hands and feet from that drug then in about probably about 15 percent or so can be permanent.

Diane Reidy-Lagunes: Yes, I totally agree.  I have one patient going on nine years of chemotherapy treatment.  And so like you said, we always try to go on those treatment breaks when we can, and sort of try to decrease the frequencies and maybe every three weeks instead of every two weeks, and those changes can be very, very helpful. 

So for patients on the call, you know, it is important to always share with your doctor when you do have side effects that are bothering you, because sometimes we don't ask in the best way and we may miss it.  And we don't want you to, like you said, the fatigue is such a harder one for us to assess sometimes.  So we want to hear it if you have those symptoms.

So, Josh, lastly, I'm going to end with the question of, is colon cancer increasing in the United States?  What do you think about that question, and the new treatments and some of the research on the horizon for that?

J. Joshua Smith:  It's a great question.  I think they're relevant.  And what we have -- what we know from colorectal cancer incidence data is that for people in their late 50s (inaudible) incidence trends are down.  But for patients that are less than 50, that the incidence trends are rising, and especially in patients that have left sided tumors, we see an increase in those cancers in the sigmoid and rectal area of the colon. 

And this is of concern because these are patients, they're in the prime of life.  And so this goes back to what I think, Robin and Andrea were mentioning why it's important for young patients to really pay attention to symptoms when they have bleeding that they should really seek attention quickly so that we can treat these tumors when they're easily treatable versus when they become more difficult to treat.

In terms of new treatments, I think things that are exciting are related to immunotherapy for MSI high are tumors that have high levels of tumor mutation burden. You know, Andrea is leading a trial and rectal cancer patients, that I think is very exciting.  There's also a trial for stage three colon cancer patients led by the colorectal (inaudible) group that is looking at immunotherapy in patients with MSI high stage three colon cancers.

In addition, there's risk and high risk stage two and stage three colon cancers and whether we can use that as a marker of clearance of disease.  And these are still research topics that are of interest and trying to get to more personalized approaches to direct care and whether or not we should or should not use chemotherapy.  So I think these are some interesting and novel, ongoing research topics.

For us here in MSK, we're very interested in terms of organ preservation for patients with rectal cancer.  And so we're trying to find better ways and more innovative ways to preserve organs in trying to enhance the number of patients that we can preserve the rectum, that is we know that the treatments that we've mentioned, chemotherapy, radiation, and then if you add on top of that surgery, these are all things that can really reduce the quality of life so if we could potentially avoid one of those things, for example, surgery that might improve patient's quality of life, so that's another unique research opportunity that's ongoing here at MSK.

Diane Reidy-Lagunes: Terrific.  So that ends our questions.  I want to thank everyone who submitted questions today and thanks to all of you who made the time to join this call.  All of you reason why we do what we do every day and we hope you found it informative and helpful.

I also want to thank our speakers.  And we plan to host more calls like this in the future and we look forward to speaking with you again.  A replay of this call will be available soon on our website, which I urge you to visit often for the latest updates at MSKCC.org.

We are dedicated to moving your cancer care forward and want to encourage you again to be in touch with your MSK doctors and care teams.  Please be safe and take care of yourselves and your loved ones and thank you, onward and upward.

Operator:  This concludes today's call.  Thank you for joining this information session for patients and caregivers.  Have a good evening.