Rectal Cancer with Dr. Steven Wexner

On this DocTalk episode, we chat with Dr. Steven Wexner, the Physician Executive Director and System Chief of Colorectal Surgery for MedStar Health. Dr. Wexner brings more than 38 years of clinical, academic, and research excellence to MedStar Health. He specializes in surgery for rectal cancer, and patients from around the world seek his expertise. 

For an interview with Dr. Steven Wexner, or for more information about this podcast, contact MedStar Georgetown University Hospital Manager Media Relations, Ryan.M.Miller2@Medstar.net.

Learn more about Dr. Wexner. 

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Transcript

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Comprehensive, relevant, and insightful conversations about health and medicine happen here on MedStar Health Doc Talk. Real conversations with physician experts from around the largest healthcare system in the Maryland DC region. Welcome to MedStar Health Doc Talk. I'm Ryan Miller and I'll be your host for today's episode. I'm joined by Dr. Steven Wexner at the Physician Executive Director and System Chief of Colorectal Surgery for MedStar Health. Dr. Wexner is based at MedStar Georgetown University Hospital and brings more than 38 years of clinical, academic, and research excellence to MedStar Health. He specializes in surgery for rectal cancer and patients from around the world seek his expertise. He is known for his innovations and research in rectal and colon cancers, laparoscopic surgery, complex reoperative pelvic surgery, and inflammatory bowel disease, just to name a few. Thank you so much for joining us today on Mestar Health Doc Talk. Thank you very much, Ryan. I'm honored to be here at MedStar Health. I'm thrilled to be chatting with you today. It's very important that we get the message out to our community in the Maryland, DC region and beyond about the importance of colorectal cancer, understanding screening, understanding symptoms, understanding treatment. We're so glad to have you on our team and definitely look forward to conversations with you on a variety of the clinical areas of expertise that you have. And today we're going to focus in on rectal cancer. Take it from the top. What would you say somebody with rectal cancer needs to know and what are the kind of questions they should be asking their provider? Unfortunately, some people don't know they have rectal cancer, particularly in younger patients where somebody might present to a physician with bleeding or even ignore bleeding and assume that it's hemorrhoids, or the treating physician treats his hemorrhoids and doesn't find out there's rectal cancer. Those patients are somewhat more fortunate in that they have a symptom that at some point will get investigated. Others unfortunately have no symptoms whatsoever, and it really highlights the importance of screening. Whether the cancer is the colon or the rectum, colorectal cancer is virtually the only cancer that is preventable by removing the precursor lesion, by removing the polyp that exists before it becomes a cancer. There are exceptions for genetic syndromes, but basically polyps can be removed and if all polyps are removed, cancer won't occur. So as Benjamin Franklin said, and it's one of my many favorite quotes, an ounce of prevention is worth more than a pound of cure. Screening colonoscopy is key. In the case of rectal cancer, it's even easier because you can sometimes feel it with the finger as an examining physician or perform a sigmoidoscopy, which is a much more limited examination. So the first thing to answer your question that people with rectal cancer need to know is they may not know they have rectal cancer. And the screening guidelines have come down in age and I believe, in my opinion, they may come down again because more and more younger people unfortunately are presenting with rectal cancer. That's troubling to hear. Some folks shy away from getting a colonoscopy, but it sounds like for a rectal screening, it's not as invasive as that. It doesn't have to be. The difference is that a rectal cancer may be able to be detected by a finger examination by a physician. A colon cancer won't because it's beyond the reach of a finger. However, a finger only covers the bottom bit of the rectum and there's a lot more that needs to be assessed and it may be assessed by sigmoidoscopy in the office if appropriate. Having said that, if a patient has a polyp or unfortunately a cancer in the rectum, then a full colonoscopy done because there's a high likelihood there may be additional lesions that need to be identified and addressed. As I mentioned at the beginning, you have brought a wealth of experience here with you to MedStar Health. How has the diagnosis and treatment of rectal cancer evolved during your career? If we look at the two separate areas, diagnosis and treatment, diagnosis has become routine by colonoscopy and the advantage of colonoscopy is any precursor lesions, any precancerous growths can be identified and removed and thus not be able to become cancer. However, there are now more reliable non-colonoscopy tests that are advertised routinely on television. They don't offer the advantage of direct visualization and they certainly don't offer the advantage of removing any polyp or biopsying any lesion, but they're available. And that's certainly been an evolution because the only test available when I was in training more than 40 years ago was fecal occult blood, which basically looks for invisible to the naked eye blood in the stool. And that test had about a 50% rate of missing growth, so it wasn't terribly reliable. And there's also the other direction, what we call false positive, where patients who would have what was thought to be blood wasn't blood and undergo a colonoscopy they didn't need. So these tests are much more specific and sensitive. What's really changed though isn't so much the diagnosis. It's what do we do after we diagnose? And we now get a rectal cancer protocol, pelvic MRI to look at how deeply the tumor grows, whether or not any lymph glands involved, whether or not any blood vessels or nerves are involved, because all of those factors help direct whether the patient would get chemotherapy and possibly also radiation therapy rather than surgery as an initial maneuver. So the first thing is we test differently. We get the MRI, we get a blood test called carcinoembryonic antigen, and we get a CAT scan of the chest, abdomen, and pelvis in addition to a full colonoscopy. So there's a very proscribed method and we'll come a little later to the importance of multidisciplinary care. The other thing that's changed is that it used to be the person who met the patient, often a surgeon just made the decision what to do. And that decision may have entailed a colostomy, a permanent bag. We have far, far fewer permanent colostomies being done today than were done 40 years ago because of better surgical technique and because chemotherapy and radiation therapy can shrink the tumors prior to surgery and allow us to maintain continuity of the intestinal tract and attach the colon from above the area of the tumor down to the rectum ranus below where the tumor is located. So we've improved our methods of treatment, dramatically improved our methods of treatment. And as an added bonus from chemotherapy and radiation, we find that anywhere, depending on the center, 30 or 40% of patients have what's called a complete response where the tumor completely disappears and the patient doesn't undergo surgery at all. So instead of just shrinking the tumor, we now eradicate the tumor without surgery, which is a major advance. There was something championed by a friend of mine from Sao Paulo, Brazil, Professor Angelita Habergama, and it's now become an international standard. It's called wait and watch. And you continue to screen the patient without surgery. So many, many differences. Another one in terms of technique is that when I trained, surgery is done through big incision and now it's minimally invasive. And minimally invasive technique might be laparoscopic through punctures, robotic through punctures. It might be transanal where the work is done up through the bottom rather than down through the belly or a combination of the bottom and the belly. And in some circumstances it might even be done by a gastroenterologist or a surgeon in the endoscopy area with a flexible instrument. So the depth and breadth of what we can offer patients now is dramatically different than it was when I started my career. Which gives more power to the patients. Absolutely. It's all about shared decision making. I guess I can touch on it now. One of the accomplishments of which I'm most proud in my career is having been the catalyst for the National Accreditation Program for Rectal Cancer. In Europe, in the 1990s and 2000s, a variety of countries started organizing what they call centers of excellence where rectal cancer was operated on or managed in a multidisciplinary team, limited numbers of centers in Scandinavia, UK, and elsewhere. We operationally, we were just individually seeing patients, radiation oncologists, medical oncologists, surgeons, with leaders from the American Society of Colorectal Surgeons, Society for Surgery, the Elementary Track, Society for Surgical Oncology, American Society of Colonelectal Surgeons, I forget which ones I mentioned, society, American Gastrointestinal Edoscopic Surgeons, American College of Surgeons, Commission on Cancer, American College of Radiology, College American Pathologists. I think that's everyone. We got together. All the leaders. Yeah. I may have repeated one, but better to repeat one than leave it out. Sure. We got together and created this multidisciplinary program, which was approved initially by the Commission on Cancer. At that time, I was on the accreditation committee in 2014 by the time I was ready to present. And then by the Board of Regents, which I was on the Board of Regents at the American College of Surgeons. And that program is now in over 120 programs in the Unitited States. And what that program consists of is that every patient with rectal cancer presenting at any of those 120 plus institutions has to be presented at the multidisciplinary team conference, which includes medical oncology, radiation oncology, pathology, imaging, radiology, surgery plus as needed, other specialists, liver surgery, spine surgery, urology, gynecology, genetics. And that is, as you said, giving the patient more choice because before I would see a patient, let's say 20 years ago and I would say, "Here's what we're going to do, end of story." Now I say to the patient, "Look, I may be 38 years into this. I probably treat more rectal cancers than just about anyone in the country, but I'm going to defer to the wisdom of the crowd. And we're going to present the results of your MRI, your CAT scan, chest abd and pelvis, your CA blood test, your colonoscopy, your pathology report at our National Accreditation Program for Rectal Cancer Multidisciplinary Team Conference. And the consensus of that group will be communicated to you thereafter. And the patients are very happy because they're getting all of these different opinions. Everybody's current in their own field and there are new things coming up every day like immunotherapy, for example, that's applicable in about 7% of patients with colorectal cancer where the tumor will disappear without surgery. So the patient is in the middle of all of this and we all operate together keeping the patient in the center of the decision making process. Thank you for walking us through that. That's really wonderful to hear. Can you break down the differences between rectal cancer and colon cancer? Does rectal cancer count as colon cancer? I like some folks tend to get the two confused. So can you just break down the differences between those? It really is a difference of anatomic location, which is significant for treatment options. For example, a cancer in the colon won't, in all probability, result in needing a bag, either temporary or certainly not permanent. A bit of the colon's removed with the lymph glands and it's put back together. So that the issue of needing to avoid a permanent bag isn't really a focus. For the rectal cancer where the rectum is sitting in very crowded real estate territory, shall we say, with the prostate gland or the vagina, with the bladder, with the sacrum, the backbone, the sidewalls of the pelvis, the anal sphincter muscles, major blood vessels, the urine carrying structures. So we have to exercise a lot more expertise in the management to avoid a permanent bag and to give the patient good function. With the colon, that's not the case. The other difference is how it spreads that the colon cancers are pretty predictable in following certain blood vessels, veins as they spread. Rectal cancer occasionally can spread in different directions, particularly the cancers very, very low down in the rectum. It really is more of a treatment difference. And there's about a little more than double the number of colon cancers as rectal cancers, roughly 150,000 a year and more or less 50,000 rectal, 100,000 colon, give or take. And that kind of makes sense because there's a lot more colon than there is rectum. The rectum's about seven inches, let's say, six inches, seven inches, and the colon is a couple of feet long. Does anal cancer and rectal cancer have the same approach to treatment? The treatment approach which we now have of wait and watch with chemotherapy and radiation, eradicating the tumor stemmed from anal cancer. So anal cancer used to be treated by removing the anus a permanent bag. And sometime in the 1970s, a very clever colorectal surgeon in Detroit, Norman Nigro, came up with a protocol that's now eponymously called the Nigro Protocol, and that was giving two different chemotherapeutic And in his first group of patients, he found that when he then went and removed the anus and rectum, there's no tumor left. So he stopped doing it and just left the anus and rectum in. And that's become the standard of care over the next 70 years since Norman Nigro first started working with it. And the rectal cancer approach that Angelita Habragama adopted in Sao Paulo starting in the 90s, late 80s, early 90s, I believe, was based on anal cancer. But anal cancer is fundamentally very different for multiple reasons. It's a different tissue type. Colon cancer arises from polyps. Anal cancer does not. Anal cancer does not arrive from polyps. There is an association of anal cancer with human papillomavirus and just like there's cervical cancer in women with papillomavirus. So it needs to be screened in high risk populations. And the mainstay of treatment is eradication with There's far less often surgery being involved and Colon and rectum are similar except the anatomy and the way they spread, whereas anal is rather distinct. When it comes to the symptoms of rectal cancer, is there anything we can watch out for and what should we do if we notice them? Certainly rectal bleeding is first and foremost. If somebody develops rectal bleeding, they should have it assessed. If somebody who happens to have a family history, a parent, a sibling, a child who's had colorectal cancer or even colorectal polyps, there's even heightened awareness, shall we say, in a lower threshold for evaluation, but really any bleeding should be assessed and be careful to have a low threshold for colonoscopy because all too often doctors will say, "Oh, it's hemorrhoids, have some fiber, soak your bottom in a warm tub, you'll be fine." You really do need at the very least to get an exam with a finger and have a discussion about the possibility of a colonoscopy. So bleeding is number one. If a patient were to get a constant sense of urgency, like they need to go to the toilet and nothing's happening or a change in bowel habits, suddenly instead of having whatever frequency somebody has, that changes and becomes more or less or more difficult to evacuate or the consistency of the stool changes, any of those things can be triggers as well. Certainly, and more advanced, unfortunately, would be unexplained weight loss. And is there any way to reduce the risk of rectal cancer? There's a lot of studies looking at things like vitamin C like aspirin and things, and there's inconsistent data for a lot of these areas. What is known overall and colon and rectum are the same here. They can be taken together. Things that are good for your heart tend to be good for your colon. So a high fiber diet, low amounts of saturated animal fats would be good. Exercise, drinking plenty of non-alcoholic, non-caffeinated beverages. These are all things that would be healthy to maintain bowel habits, perhaps taking a supplement of psyllium fiber, which is an insoluble husk of fiber that tends to bulk up the stool might be of some benefit, but unfortunately there's no real panacea to say we can prevent it. I wish that there was. I wish we could put ourselves out of business and have patients never again get rectal cancer, but for now we can just live a healthy lifestyle. Certainly if one has a family history, need to be very vigilant. Should be screened earlier than protocol? Exactly. If somebody has a first degree relative, they should start screening at least 10 years younger than the youngest first degree relative. Okay. And what is the standard age again for our. Listeners? 45 tends to be the recommendation at present. It's come down over the years. Not too long ago was 50, now 45. And I suspect, as I said earlier, it may well end up being 40 at some point in the not too distant future. Just the number of people we're seeing who tragically come in. And again, because the symptoms are not listened to by the provider or maybe the patient doesn't push enough either. And then unfortunately they come in with more advanced disease when in all probability it could have been an earlier stage had it been evaluated at first presentation. Rectal cancer treatment often involves surgery to remove the cancer. How do you know when surgery is required? What are some of the other treatment methods? As we were discussing a little bit earlier, there's a lot of different treatment options for surgery now, and that decision is made by what I call the wisdom of the crowd, the consensus of all the people attending the National Accreditation Program for Rectal Cancer Multidisciplinary Team Conference, which every patient is presented. And I had the privilege of chairing the NAPRC for the US, for the American College Surgeons Commission on Cancer about two months ago, I finally finished chairing it and have seen it grow from no programs, as I say, to over 120 programs. So that discussion is made. Now, it would not be the purview of the group to tell the surgeon exactly what type of operation or what approach, but that's something the surgeon talks to the patient about. For example, a very early rectal cancer, what we would call T1, meaning it's just limited to the innermost lining. We might say, "Well, we can remove this tumor through your bottom with a collotoscope. We can remove it through your bottom in the operating room, some specialized equipment, or we can remove the entirety of the rectum and lymph glands." And then we discuss the pros and cons of each of those surgical approaches with the patient and the patient's family and anyone else the patient would like to engage in the conversation. And arrived at shared decision making, the patient would say,"Well, something I'd like to undergo the transanal excision, have it removed from my bottom, or no, I don't want to risk that there might be tumor cells lurking. I'd rather have you remove the rectum and the lymph glands and do a reconstruction.". In terms of recovery, after someone has surgery for rectal cancer, how long would you say they're in the hospital and how quickly will you know whether or not the surgery you performed was successful? One of the wonderful things about minimally invasive surgery is how patient friendly it is. And a lot of the advantages of minimally invasive surgery are seen early on. In other words, hospital stays are shorter because there's less pain. The bowel function returns more quickly. So patients typically are in the hospital no more than two or three days unless they have an ileostomy, a temporary bag protecting the joint up. And that remains one of the issues of rectal cancer. So on the one hand, we can shrink the tumor down with chemotherapy and radiation therapy or just chemotherapy. But on the other hand, that step prior to surgery unfortunately increases the risk of the joint up not healing properly and therefore we do make a temporary bag upstream. That temporary bag will keep the patient in the hospital longer because they need to learn how to manage it and that can add to end up being about five or six days. So let's say between the two groups, the average might be four days for patients these surgery as we look around the country. If the surgery is done through the bottom, it may be a daycase outpatient procedure. Are you involved in any rectal cancer research and why are you optimistic about this field? I've been involved and continue to be involved in a lot of rectal cancer research. I think during the last year, I've probably published at least 20 studies. I've done randomized control trials with different surgical techniques. I was the lead and senior investigator for the trial that looked at the combination of operating through the bottom and through the belly at the same time with what's called transanal total mesoretical excision. I believe those two studies next now three were published in the last two years and a lot of other projects underway. The fundamental threat of all of these studies is multifold. The common denominator is improved quality of life. The common threads are recognizing it occurs in younger patients, recognizing that we can safely treat older patients. Some of the things we've done, finding techniques that are more patient friendly and just as efficacious or perhaps more efficacious than the standard of care intervention. So these are all things that I'm working on and I'm thrilled to be at MedStar Health, Georgetown University, particularly with the having a National Cancer Institute Center at which I'm working is a tremendous opportunity to really help advance the science of colorectal cancer management. We are honored to be the only NCI comprehensive cancer DMV. Dr. Wexner, why should patients choose MedStar Health for colorectal surgery? Great question, Ryan. And I think that there are many reasons for it, one of which we were just discussing, and that is the NCI designation plus the Commission on Cancer designation, plus two of our three teaching hospitals, Hospital Center and Franklin Square are national accreditation program for rectal cancer accredited institutions. And hopefully very soon also, because we're working on it now, we will seek and hopefully get that accreditation for MedStar Georgetown University Hospital. So we'll have it at all three of our centers. We have a large number of highly skilled, very technically gifted surgeons who have great judgment and wonderful hands working at those three hospitals and at others, but certainly focusing their efforts at Franklin Square, at Hospital Center and at Georgetown. But importantly, we don't operate in a vacuum. And again, I don't mean operate in the terms of performing operations so much as go about our daily lives because we have phenomenal colleagues at each of those hospitals in radiation oncology, medical oncology, gastroenterterology, pathology, imaging, radiology and the like. So patients come here, it's one stop shopping. It's not that I have to go see a surgeon here and then drive across town to see my radiation oncologist and then go somewhere else to get my x-rays done and hope they get sent and track down the pathology slides because the gastroenterologist did the colonoscopy at a freestanding ambulatory surgery center and I can't get the slides. It's one stop shopping. It's very convenient. It's shared conversation and very importantly, it's that group getting together and discussing every patient as a group to ensure that every patient benefits from the wisdom of the crowd. Well said. I've been talking with Dr. Steven Wexner at MedStar Georgetown University Hospital in Washington DC. Thank you for sharing your expertise with us today on MedStar HealthDoctor. Thank you, Ryan. It's been an enjoyable conversation. My parting words to the listening public would be take heed, get screened. Rectal cancer is in most cases preventable with appropriate screening. Look forward to talking to you again down the road. Thank you, likewise.