Colon Cancer: The Diagnosis

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Guest: Dr. Brenda J. Hoffman - Gastroenterology and Hepatology

Host: Dr. Linda Austin – Psychiatrist

Announcer: Welcome to an MUSC Health Podcast.

Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Brenda Hoffman, who is Professor of Medicine and a Gastroenterologist at the Digestive Disease Center here at MUSC. Dr. Hoffman, one of your areas of great interest is colon cancer, which you earlier told us is the second most common form of fatal cancer in this country. Let’s imagine someone has just had their first colonoscopy and there is bad news. You tell them that you believe that they may have cancer of the colon. What happens next?

Dr. Brenda J. Hoffman: It depends upon where the cancer is located. If the cancer is in the rectum for example then the next step would be to try to see how deep the cancer goes within the wall or through the wall and whether there are any lymph nodes around it. That helps to decide whether the patient gets some treatment probably chemotherapy and radiation to shrink it and get rid of the lymph nodes before an operation, but the rectum is unique and the rest of the colon. There really are no specific guidelines that say you have to obtain a CT scan of the abdomen or pelvis to look at the colon and to stage further, but most people do. So, usually the next step would be to get a blood test that looks at a tumor marker for colon cancer that’s used to see if we can follow individuals after their surgery.

Dr. Linda Austin: And what is that tumor marker called?

Dr. Brenda J. Hoffman: It goes by initials called the CEA. I will leave it at that because the terms are so long, but it is a marker that increases when people have colon cancer and particularly if the cancer has spread, it may be quite high. It is then used in general as a screening test for an individual walking around and getting a routine blood test because it can be elevated if you smoke cigarettes or there may be other reasons. So, it can give you misinformation as well, but when it’s used in this fashion, it’s a very useful test. They also will probably have a CT scan of the abdomen or pelvis to look at the liver and to look at the area around the bowel. After that most commonly, the patient would have an operation to take care of this and what type of operation they have really depends on the size and the location.

Dr. Linda Austin: Could we pause and talk about the stages of colon cancer? I think we doctors talk a lot about staging and lay people may not know what the different stages mean. What are the stages of colon cancer?

Dr. Brenda J. Hoffman: We stage colon cancer from 1 through 4 and of course 4 is worse because that’s metastatic disease. A patient with an early colon cancer can have an excellent life expectancy. Individuals even at stage 4 can have a reasonable five-year survival if they have therapy. It is our goal to not have them develop cancer by doing the screening procedure, so that we take out the lesions that are precancerous. But if you do have a colon cancer, it is staged based on the death of the tumor as it goes through the wall whether it goes through the wall and whether it is growing into anything nearby like the bladder, the vagina, or the prostate and also whether it has spread. That’s how we determine those stages.

Dr. Linda Austin: So, you then make a determination about the surgery, is that correct?

Dr. Brenda J. Hoffman: Yes, and that will be from the information that we have gained from the x-rays and from the endoscopic appearance and location.

Dr. Linda Austin: Let’s take the worst-case scenario. Let’s imagine, it is stage 4 and it in fact has spread within the abdomen. What kind of treatment should a person expect?

Dr. Brenda J. Hoffman: If there is one metastasis to the liver, that individual can expect that their surgeon would remove a portion of the liver at the same time. If they were unfortunate enough to have multiple lesions within the liver, for example across the left and right sides, then they would probably be shifted more toward chemotherapy. They may still have an operation to avoid blockage of the bowel by the tumor, but in terms of treatment of their metastasis to the liver, it would fall more under a systemic effect of chemotherapy.

Dr. Linda Austin: How effective is that chemotherapy for cancer of the colon that has spread?

Dr. Brenda J. Hoffman: It is very effective these days and there are types that can be done by mouth, so that individuals are not necessarily bound to an IV infusion site. So, there has been a lot of headway in colon cancer within the last few years and that’s why we see an improvement in survival for stage 4.

Dr. Linda Austin: Do people getting that form of chemotherapy have the typical side effects like hair loss and severe nausea and so forth?

Dr. Brenda J. Hoffman: They have them to a lesser extent. It really depends on whether or not they have to use a combination of medications for them as to how sick they become, but some of the ones that they use in pill form really have more limited side effects than what we have seen in the past.

Dr. Linda Austin: It sounds as if from what you are saying that because these polyps are slow growing for the most part except I think you said for the familial form, but in general it’s slow growing. But the secret is really to get the screening, get the polyps out before they are cancerous, or before they have invaded the wall of the colon, is that right?

Dr. Brenda J. Hoffman: That is key; by the time, you develop symptoms usually the tumor is more aggressive.

Dr. Linda Austin: Symptoms such as?

Dr. Brenda J. Hoffman: The worst ones would be bowel blockage or perforation where the colon has actually formed a hole near the cancer. Those have the worst prognosis because they are more advanced disease. If you have bleeding for example, if you have rectal bleeding, that may still be relatively early cancer if it’s in the rectum, but for the most part once you develop obstruction, bleeding, weight loss, that’s unexplained; they are usually far advanced diseases and we don’t want to be at that stage. We want to get you where we can still take this out as a simple procedure and have no risk of recurrence.

Dr. Linda Austin: Dr. Hoffman, thank you so much for talking with us.

Dr. Brenda J. Hoffman: Thank you.

Announcer: If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection at 1-843-792-1414

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