In this issue, five Maryland physicians describe advances in treating rectal, peritoneal and skin cancers and the role of cancer survivorship programs in caring for those who survive cancer.
By: Linda Harder
Photography by: Tracey Brown
Trends in Treating Rectal Cancer
Over the decades, physicians have learned much about how to best treat rectal cancer. Hopkins colorectal surgeon, Jonathan Efron, M.D., and his team are investigating the efficacy of laparoscopic and robotic procedures, endorectal brachytherapy and other state-of-the-art treatments for this disease.
“In the past, we gave radiation therapy after surgery,” recalls Dr. Efron. “Then, in the 1990s, large randomized European trials showed a better response when patients were given adjuvant therapies before surgery and American surgeons subsequently found it decreased recurrence rates. Today, most patients with rectal cancer get neo-adjuvent therapy prior to surgery.“
Dr. Efron explains, “We’re using a multi-disciplinary approach. Our rectal cancer center is composed of radiation oncologists, medical oncologists, surgical oncologists, colorectal surgeons, nuclear medicine specialists, pathologists and others. Typically, patients come to us after having had a colonoscopy or sigmoidoscopy that identifies rectal cancer.
“We evaluate rectal cancer using a battery of radiology tests, usually MRI of the pelvis or CT of the abdomen and pelvis,” Dr. Efron continues. “On the same or next day, the patient can see the surgeon, radiation oncologist and medical oncologist. We can coordinate with the patient’s medical and radiation oncologist back home or provide those therapies here. The vast majority of patients proceed with surgical intervention about eight weeks later. About 20% of patients – those for whom radiation and chemotherapy have apparently completely eradicated their cancer and those who are too sick to undergo surgery – will receive watchful waiting instead.”
Laparoscopic and Robotic Approaches
“With colon cancer, we know that laparoscopic and robotic surgery results are comparable to open excisions, but we’re not yet sure that that is true for rectal surgery,” Dr. Efron notes. “Hopkins is involved in a large, randomized trial across the country, but we won’t know the results for another three to four years.”
Total Mesorectal Excision (TME) Surgery
Studies have shown that total excision of the mesorectum, fatty tissue directly adjacent to the rectum that contains blood vessels and lymph nodes, provides superior outcomes and has more than halved the recurrence rate. TME is appropriate for patients with tumors in the middle or lower two thirds of the rectum.
Dr. Efron comments, “In the older technique, the lateral aspects of the rectum were divided and left in. Now, we excise everything. The five to 10 year recurrence rate has decreased to 5-10%.
“In the 1980s, a tumor anywhere in this area would have required a colostomy,” he continues. ‘Now, using pre-op radiation therapy, many people are candidates for the preservation procedure. We can often shrink large tumors to alter our operational plan and keep the anal muscles intact. Patients typically get a temporary colostomy but can avoid a permanent one. Less than 1% of patients experience some urinary continence and sexual dysfunction issues as a result of nerve damage.”
High-Dose-Rate Endorectal Brachytherapy (HDRBT)
Hopkins is conducting a pilot study of HDRBT for patients with clinical stage T2N1 or T3N0-1 resectable rectal cancer. This approach, first pioneered in Montreal, uses an anal probe to deliver brachytherapy over a four-day period in lieu of five weeks of external beam radiation therapy. The trial started in early 2012 and results won’t be known for several years. “We’ve had excellent results with 10 patients to date, and we plan to test it on about 20 more,” concludes Dr. Efron.
Cytoreductive Surgery and HIPEC
For years, the only treatment for patients with peritoneal dissemination of cancer was chemotherapy, which has poor results. Then, in the 1990s, a few surgeons began performing cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) at the completion of surgery to destroy remaining cancer cells in the abdomen. This is a lengthy procedure taking seven to 12 hours that requires a highly experienced surgical team. Cytoreductive surgery refers to the complete removal of all visible cancer or only leaving cancer nodules less than 2.5 mm in size. This is followed in the same setting by HIPEC to destroy remaining cancer cells in the abdomen.
Colorectal cancer with peritoneal dissemination is the most common carcinoma treated by cytoreduction with HIPEC. Others include appendix, ovarian, gastric, primary peritoneal, sarcoma and mesothelioma.
Refer Early, Before Chemo
Unfortunately, patients are often referred late, after they’ve received chemotherapy and multiple surgeries. Armando Sardi, M.D., director of the Institute for Cancer Care at Mercy, states, “As soon as patients are diagnosed by CT or surgery with peritoneal spread, they should be referred. Chemotherapy makes the patient debilitated.”
Dr. Sardi says, “The surgeon has to be prepared to perform an extensive surgery, which may require the removal of several organs at one time. Most of the patients I perform this surgery on have extensive disease and this is their last hope. However, there’s so much data in the literature now that supports cytoreductive surgery with HIPEC, and thanks to the Internet, patients are getting to us earlier.”
Media coverage is misleading, according to Dr. Sardi. “A New York Times article* described it as a horrendous surgery but it’s not.” Insurance is another barrier. “Medicare doesn’t want to recognize this procedure,” he adds.
“In the procedure, surgeons remove all of the visible tumors and attempt to preserve as many organs as possible,” Dr. Sardi continues. “Some 85% of the time, we remove all visible tumors of 2.5mm or greater. Then, the peritoneal area is bathed in a heated chemotherapy solution, which is the most effective way to kill remaining cancer cells. Patients with colon, rectal and ovarian cancer often need follow-up chemotherapy, which we coordinate closely with medical oncologists.” However, there is no data that all patients with cancer of the appendix or mesothelioma benefit from follow-up chemotherapy.”
Following the procedure, patients spend about 12 days in the hospital, start eating after about one week and take two months to fully recuperate. Most patients are 40 to 50 years old, but some are in their 20s or 80s.
The mortality rate for an experienced surgeon is surprisingly low. Dr. Sardi comments, “In about 400 procedures, we had only one mortality and that was in 1998. Very few treatments have as good outcomes as HIPEC, yet it remains underutilized.“ A study in the Journal of Clinical Oncology found that merely 4% of patients with colorectal cancer and peritoneal dissemination who were given only chemotherapy were alive after five years. A prospective randomized trial in patients with colon cancer using HIPEC in addition to chemotherapy showed a 45% survival at 5 years if the cancer was completely removed.
“For patients with Stage IV cancers that have spread to the peritoneum, very few treatments have outcomes as good as HIPEC. In fact, a patient I treated in 1994 is still alive today,” concludes Dr. Sardi.
Mohs Surgery: A 99% Cure Rate
Annapolis dermatological surgeon Lisa Renfro, M.D., has performed more than 15,000 surgical excisions and 10,000 Mohs surgical procedures in her nearly 20 years in practice. Even for a dermatologic surgeon, it’s an astounding indication of the prevalence of skin cancers. With 3.5 million skin cancers diagnosed annually, it is the most common cancer in the U.S., affecting more people each year than breast, prostate, lung and colon cancers.
Mohs surgery uses microscopic examination of skin cells to trace the skin cancer and completely remove it. Performed under local anesthesia, the tumor is excised with a narrow margin and immediately processed in an on-site histological lab. There, it is color coded with dyes and the tissue is precisely mapped. Under the microscope, the tissue is analyzed for remaining cancerous cells; when indicated, a second thin layer of tissue is removed from the exact site that contains cancerous tissue. Most patients only need one stage; rarely a second or third stage is necessary to achieve cancer-free margins.
The removal of each tissue layer takes about 15 minutes, but each tissue analysis requires one to two hours due to histologic processing. In most cases, the dermatologic surgeon performs reconstruction of the surgical defect.
The Mohs procedure offers the highest success rate of all skin cancer treatments – greater than 99% for new cancers and 95% for recurrent carcinoma –and preserves the maximal amount of normal tissue. Dr. Renfro remarks, “Mohs surgery, by conserving tissue, allows the best cosmetic and functional outcome. Since many skin cancers are on the face, that’s an important advantage.”
Mohs Surgery Indications
Basal cell carcinoma, squamous cell carcinoma and other skin cancers that:
- Develop on areas where preserving cosmetic appearance and function are important
- Have recurred after previous treatment or are likely to recur
- Are located in scar tissue
- Are large
- Have edges that are ill-defined
- Are aggressive and rapid-growing
Advice for PCPs
“When evaluating skin lesions, primary care physicians should be vigilant for new or changing lesions,,” Dr. Renfro advises. “Be on the lookout for any skin lesion that is pink, scaly, or pearly, and is enlarging or bleeding. Melanomas, although usually pigmented, may be subtle in appearance and occasionally do not reveal any pigment. Any unusual lesion should be biopsied.”
Dr. Renfro also urges primary care physicians to check patients’ Vitamin D levels and to encourage patients to protect themselves from even small doses of sun exposure. “The American Academy of Dermatology’s position is that people should get any additional Vitamin D from diet and supplements, not sun exposure,” she says.
Mohs Advances and Future Applications
Dr. Renfro comments, “While it’s controversial, some surgeons are using Mohs for melanoma in situ, employing special immunostains. MART-1 is the stain of choice for this type of skin cancer. Immunostaining is used in addition to H & E staining. Cytokeratin stains are used for large, advanced, recurrent cancers.”
In the future, Mohs is expected to have applications for locally invasive tumors with contiguous growth patterns in the prostate, cervix and larynx.
Cancer Survivorship Programs
With more people surviving cancer than ever before – estimated at over 80% – health professionals are recognizing that cancer survivors need better coordination of their ongoing post-treatment care than has been available to date. That has led to the onset of Cancer Survivorship Programs, now a required component of accreditation from the Commission on Cancer of the American College of Surgeons.
Barry Meisenberg, M.D., director of the Cancer Institute at Anne Arundel Medical Center, observes, “Cancer patients have medical, social and psychological issues that aren’t being well addressed. There are gaps in communication between the oncologist, primary care physician, other providers and the patient. A plan for follow-up care is not always clear. Physicians worry they don’t have enough information on the patient’s treatment. Patients may be caught in between and don’t know where to go for screening for other medical problems. For example, who does the follow-up for back pain and how do you treat it in a patient with cancer?”
AAMC’s initial survivorship program was created for those with breast cancer, but it is expanding to patients with prostate, head and neck, lung and other cancers.
Survivorship Care Plan Aids Coordination
“The survivorship program at Anne Arundel Hospital develops a detailed Survivorship Care Plan with the patient and sends it to the primary care doctors,” says Ravin Garg, M.D., medical oncologist with Annapolis Oncology Center. “It describes the various treatments the patient has undergone and the possible long-term side effects. For example, with a breast cancer patient, it details when a patient should receive a mammogram and other follow-up tests. All the details of the patient’s therapies, including dates and types of therapies, lymph node involvement, where the radiation was directed, what medications the patient is taking, etc., are contained in a single document.“
Dr. Garg remarks, “It’s incredible what cancer patients go through – typically surgery, radiation, sometimes chemotherapy and anti-estrogen therapy. Each has short and long term side effects, such as lymphedema after breast cancer excision. To patients and their loved ones, it can feel overwhelming.
“Primary care physicians should be aware of the risks of blood draws and blood pressure readings on the arm with lymphedema, but also be informed that sometimes certain exercises are no longer contraindicated for these patients,” he continues. “Physicians also need to be aware of what a low white or red blood cell count could mean in a cancer patient (myelodysplasia from chemotherapy exposure).”
Psychosocial aspects are also part of the survivorship assessment and follow-up. Dr. Garg notes, “Depression and anxiety are under-diagnosed in survivors. It can be difficult to address the psychosocial issues in a 20-minute visit with the oncologists, so it is important that this aspect of a patient’s longitudinal care is not forgotten.
“Nutrition is another critical and often overlooked aspect of recovery,” he states. “I tell people to eat a healthy diet, drink lots of water and try get 150 minutes of moderate exercise every week rather than overdoing it with supplements.”
Armando Sardi, M.D., surgical oncologist, is director of The Institute for Cancer Care and director of Surgical Oncology at Mercy Medical Center.
Jonathan Efron, M.D., colorectal surgeon, is an associate professor of surgery and chief of Ravitch Service, Johns Hopkins Medicine.
Lisa Renfro, M.D., is a dermatologic surgeon at Annapolis Dermatology Associates and an attending physician at Anne Arundel Medical Center.
Barry R. Meisenberg, M.D., hematologist/oncologist, is director of the Cancer Institute at Anne Arundel Medical Center.
Ravin Garg, M.D. is a hematologist/oncologist at Annapolis Oncology Center.
* Pollack, A. (2011, August 11). Hot Chemotherapy Bath: Patients See Hope, Critics Hold Doubts. The New York Times.