Colorectal Cancer Expertise in MUSC Health Midlands Division

We are marking Colon Cancer Awareness Month with a valuable discussion about the importance of early detection of colorectal cancer as well as the latest treatments that can offer hope and improved outcomes for patients. In this episode, two colorectal surgeons from MUSC Health Midlands, Dr. Kasim Mirza and Dr. Leslie Jarrott Moore, discuss MUSC’s multidisciplinary approach and full spectrum of treatment options for patients diagnosed with colorectal cancer in the SC Midlands.

Quotes

“If you're presenting to our clinic, or our colleagues in Charleston, you can know you're going to get a good multidisciplinary approach to give you the most up-to-date and best cancer treatment possible. And we'll be with you every step of the way — through the diagnosis treatment phase and then surveillance, we're going to be with you for years to come.”
— Dr. Kasim Mirza

“It's important that you have physicians that are qualified and competent and that you know are going to see you through it. Putting your trust in a physician who's done it before, who's seen cases just like yours, we can see you through a scary time.”
— Dr. Jarrott Moore

Topics Covered in This Show

• When a patient is diagnosed with colorectal cancer at MUSC Health, their case is included in a multidisciplinary conference involving colorectal surgeons, medical oncologists, radiation oncologists, radiologists and pathologists, where a treatment plan is decided upon as a group.
• In the past, access to MUSC’s multidisciplinary team required patients in the Midlands area to travel far distances. Now that the new colorectal team has been established in the MUSC Health Midlands Division, patients can find this exceptional care close to home.
• Diagnosis of either colon cancer or rectal cancer can differ based on where the tumor is found. Both require a CAT scan of the chest, abdomen, and pelvis, and baseline blood tests. Rectal cancer often requires an MRI as well. Treatment can include chemotherapy, radiation, and surgery.
• Cancer primarily spreads through the lymphatic system and/or through the bloodstream. When spreading through the bloodstream, colorectal cancer can spread further from where it started, often to the liver or the lungs.
• Stage 1 cancer includes a partial-thickness tumor that doesn't involve the lymph nodes and hasn't spread. Stage 2 cancer is a full-thickness cancer but does not involve the lymph nodes and hasn't spread. Stage 3 cancer involves the lymph nodes but not a distant spread.
• MUSC offers the full breadth of surgery for colon cancer. Whether it be minimally invasive, laparoscopic surgery, robotic surgery, transanal surgery or traditional open surgery, our team of experts is adept at them all.
• Minimally invasive approaches offer patients a speedier recovery, and in most cases, less pain and less time in the hospital without sacrificing any of the outcomes.
• After treatment for colorectal cancer, a surveillance colonoscopy will be performed a year later and then more frequently for the first 10 years after treatment.
• In addition to family history, risk factors for colorectal cancer can include smoking, alcohol use and obesity. To reduce one’s overall risk, living a healthy lifestyle that includes exercising, reducing your alcohol intake and avoiding smoking and tobacco use, can be vital.
• New studies are presently looking at how bacteria living in our gut, colon and/or rectum may interplay with our biology, impacting factors like inflammation within the colon and rectal wall, which can increase risk.

Read the Transcript

[00:00:00] Erin Spain, MS: Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. On today's episode, we're marking Colon Cancer Awareness Month with a valuable discussion about the importance of early detection and the latest treatments that are offering hope and improved outcomes for patients. Joining me are two colorectal surgeons from MUSC Health Midlands division. Dr. Kasim Mirza And Dr. Jarrott Moore. Dr Mirza, can you start us off today by talking about a colon cancer diagnosis? What is it like when a patient is given this diagnosis, and what are the steps that you take them through after receiving this news?

[00:00:54] Dr. Kasim Mirza: To all patients who present with this diagnosis, it can be overwhelming. It's never welcome news to hear. And I would always tell people that it's better to know than to not know. And that first step of having a diagnosis, now we're able to really get a grasp on what the problem is and get you treated. And if you're presenting to our clinic or, our colleagues in Charleston, you can know that you're going to get the right approach and a good multidisciplinary approach to give you the most up to date and best cancer treatment possible. And we'll be with you every step of the way through the diagnosis treatment phase and then surveillance, we're going to be with you for years to come.

[00:01:37] Dr. Jarrott Moore: It's important that you have physicians that are qualified and competent and that you know are going to see you through it. Putting your trust in the physician who's done it before, who's seen cases just like yours, we can see you through a scary time.

[00:01:53] Dr. Kasim Mirza: And I see our role as specialty surgeons, really one where I want to put the patient back in the driver's seat where they're making decisions and our job is to help them make the best informed decisions they can. Every patient's different and what's right for one patient may not be right for another patient. And our job is to help them through that decision making process as much as it is to do the technical process treating a cancer surgically.

[00:02:19] Erin Spain, MS: And as you mentioned to you two are surgeons, but there is an entire team that you work with to help a patient once they've been diagnosed with cancer. Tell me about that team.

[00:02:30] Dr. Kasim Mirza: if a person is diagnosed with cancer, they are sent to us, and then part of their care is a multidisciplinary conference, where the vast majority of cancer patients are presented, where it involves not only the colorectal surgeons but also the medical oncologist, the radiation oncologist, the radiologist and the pathologist. We come up with an individualized treatment plan for each patient based on a multidisciplinary approach. We do offer the full breadth of surgery for colon cancer, whether it be minimally invasive or traditional open surgery, we are all quite adept at both. From beginning to end, patients are going to have a pretty broad team of people taking care of them from start to finish.

[00:03:09] Erin Spain, MS: In the past, to have had access to this multidisciplinary team from MUSC Health, you may have had to travel far. You may have had to go to Charleston. Tell me about the convenience of offering access to all MUSC Health has to offer here in the Midlands Division.

[00:03:27] Dr. Jarrott Moore: We've been here in the Midlands now for about five months. And one of the first things we wanted to do was to start up this multidisciplinary conference. And we typically meet twice per month. It's always sort of interesting how different specialties approach cancer and the benefits of a multidisciplinary conference where you can sort of bounce it off of your colleagues because oftentimes they'll have ideas that you didn't have and vice versa, you'll have ideas that they didn't have, but when you put all your heads together, you can typically come up with an individualized plan that's optimal.

[00:03:54] Erin Spain, MS: As I mentioned, March is colorectal cancer awareness month. But it's important to note that there are differences between colon cancer and rectal cancer. Can you talk about those?

[00:04:05] Dr. Kasim Mirza: So for colorectal cancer, some of the treatment really depends a lot on whether the tumor is found in the colon or the rectum, but for any cancer, the next step after a diagnosis is to get more information and fully understand what the stage of the cancer is. So for a colon cancer, that would involve getting a CAT scan of the chest, abdomen, and pelvis typically, as well as some baseline blood tests, including a CEA blood level, which is a tumor marker that we'll use to monitor throughout the courses of treatment. For rectal cancer, that also involves getting a separate type of imaging with more detail on the pelvis called an MRI.

[00:04:51] Dr. Jarrott Moore: So you have the diagnosis phase, then a staging phase, which is mostly imaging and some lab tests, and then comes the treatment phase. And sometimes that means going straight to surgery, and sometimes it means starting with chemotherapy. Sometimes it means starting with radiation; it all depends on exactly the location of the tumor. If it's in the colon, it's generally going to be, surgery upfront unless it's a very advanced cancer, in which case sometimes chemotherapy is used upfront and sometimes chemotherapy without surgery is used if it's a very advanced cancer.

[00:05:20] Erin Spain, MS: Remind us of the ways that cancer spreads in the body.

[00:05:24] Dr. Kasim Mirza: The two ways cancer is generally spread are through the lymphatic system. So, it's a lymph node. Lymph nodes exist all over the body. A lot of times patients will think of lymph nodes around their neck when they get sick or in their armpits. But we also have lymph nodes inside our belly that are around all our organs. And in the case of the colon and the rectum, there are lymph nodes that are right around those organs. So that's one place that cancer can spread. And another would be through the bloodstream. And spread through the bloodstream tends to have cancer cells spread further away from where they started. In the case of colorectal cancer, most commonly, if there is distant metastatic spread, it would be to the liver, which is another intra-abdominal organ and the lungs, which are in the chest. There are other more rare and distant disease spread that can occur, but those are the most common.

[00:06:16] Dr. Jarrott Moore: So after we do the staging workup preoperatively, there's postoperative staging that occurs and just sort of to allude to what Dr. Mirza was saying, if it's a stage four cancer, that means it's spread to some distant organ, again, typically either the lungs or liver. But the other three stages are broken down into how deeply it involves the bowel wall and whether or not the lymph nodes around it are involved. And each of those has subcategories, but sort of briefly, a stage 1 cancer is one that's a partial thickness tumor that doesn't involve the lymph nodes and hasn't spread anywhere. A stage 2 cancer is a full thickness cancer. Full thickness of the wall of the bowel but does not involve the lymph nodes and hasn't spread in a stage 3 cancer is one that involves any distance of or any thickness of the bowel wall, but also involves the lymph nodes but not a distance spread.

[00:07:05] Erin Spain, MS: Your team can offer minimally invasive approaches to these surgeries. Tell me about that and how these types of minimally invasive procedures can help people recover faster.

[00:07:15] Dr. Kasim Mirza: So minimally invasive approaches for colon and rectal cancer generally include laparoscopic surgery, robotic surgery and transanal surgery. Our primary goal as cancer surgeons is to do the best cancer operation we can with the goal of being treating and curing cancer, and in some cases treating and relieving symptoms when a cure is not possible. Minimally invasive approaches offer patients a generally a speedier recovery and in most cases, less pain and less time in the hospital without, sacrificing any of the outcomes as far as an approach and treatment for their cancer diagnosis.

[00:07:57] Erin Spain, MS: Can people lower their risk of colorectal cancer coming back after they've had surgery and treatment? What can they do to prevent it from returning?

[00:08:07] Dr. Jarrott Moore: People who have stage 1 and stage 2 cancers are generally treated solely with surgery. If you have stage 3 cancer and you're treated solely with surgery, your risk of, of it returning is on the order of about, 50%. But you can significantly reduce that risk by having chemotherapy given after surgery. beyond surgery and chemotherapy, the longer term surveillance, you're not really focused on necessarily preventing cancers, but looking for recurrence. The best thing one can do to prevent a new cancer from forming is to have colonoscopies. And so, all of these cancers will start, at some point as an abnormal cell becomes polyps and those polyps become cancer. Not all polyps become cancer, but that's where the cancers tend to come from, at least the types that we're talking about. And having colonoscopies and catching those polyps early, we know that particular patient is in now in a different category, they're in a higher risk category from the average population because they have proven that they can develop polyps and those polyps can turn into cancer within them. So they are at higher risk than the average person and so they will have much more frequent colonoscopies after they've had surgery for colon cancer than the average person would. Someone who's at average risk does not require colonoscopy as frequently as a person who has already proven that their body can develop cancers.

[00:09:28] Erin Spain, MS: How frequently would someone be getting colonoscopies after they've had that initial diagnosis and surgery and treatment?

[00:09:35] Dr. Kasim Mirza: After treatment for colorectal cancer, a surveillance colonoscopy will be performed at one year and then more frequently for the first 10 years after their treatment. Patients who've had a diagnosis of colorectal cancer will never have an interval longer than five years, given that we know, based on their biology, that they have a higher risk and ability to form colorectal cancers.

[00:09:57] Erin Spain, MS: March is all about colon cancer prevention and reminding people about screenings. What are some lifestyle things that people can do to help lower their risk of developing colon cancer or possibly having colon cancer return? Are there things that we can do in our daily life to improve our risk?

[00:10:16] Dr. Kasim Mirza: As is true of a lot of cancers, there are some known risk factors that patients who develop colorectal cancer oftentimes will have as risks. And that includes smoking, alcohol use, obesity. When we think about these sorts of things, the approach to reducing your risk overall would be living a healthy lifestyle, exercising, reducing your alcohol intake, avoiding smoking and tobacco use.

From a hereditary standpoint, there's a subset of colorectal cancer that does have a hereditary component. And a big point there for all patients to know would be to look into your family history, talk to your family members. It's always better to know than to not know. And when we can successfully find out about patients' family histories, sometimes an entire family can be more aware of what their risk is based on their family history and their heritable risk factors. And once we know that, it can be screened more appropriately and reduce the risk of developing a colorectal cancer, or if they do develop one, making sure that it's caught at an early standpoint when it's treatable and curable. A lot of studies that are going on now as well about risk factors and things that might increase the likelihood of developing colorectal cancer. There are studies looking at how the bacteria that live in our gut and our colon and rectum may have a large interplay with our own biology and change factors like inflammation within the colon and rectal wall, and the risk of developing a colon cancer. A general approach to this would be having a healthy diet, avoiding as many processed foods as you can. There was a study looking at consuming red meats that showed a small increase in the risk of colorectal cancer, and that's certainly something that we can point to. And I think of that as kind of the tip of the iceberg in terms of a holistic approach to taking care of your health, eating a good diet, avoiding lots of processed foods, exercising, and avoiding toxins like tobacco, smoke and alcohol as part of an approach to reducing your risk of colorectal cancer?

[00:12:29] Dr. Jarrott Moore: For solid organ tumors, particularly for colon cancers, you have to think about what a cancer is and, it is mutated genetics within a cell. Every cell in your body divides, all the time. And so the more frequently a cell divides, the more likely there are to be mutations. And people's cells have mutations all the time. And your own immune system can be affected. can sort of seek out those abnormal cells and, and destroy them before they take hold. And so you have your own immune system that sort of helps prevent cancer. But the more frequently something mutates, the more frequently it divides, the more frequently there are mutations and cells that divide quite rapidly, like the lining of the gut. The lung cells, those ones that are going to be at higher risk of developing cancers. And so, on one hand, you have to understand that there are mutations that happen all the time. And you can do things that increase your risk of cancer mutations occurring. If you do things that are toxic to the local environment like smoking, that increases the risk of mutations. So say you had one in a million of your cells had a mutation in it, but then you smoke and these are just made up numbers. But say you smoke and now you have a hundred out of a million still, it's a, it's a very small number. But you have a hundred times the mutations that you would otherwise normally have, and those will eventually escape your own immune system. So the way to lower your risk is to avoid things that will increase the rate of mutation within your dividing cells. I mean, your dividing cells are healthy cells, but when one escapes and it's abnormal or cancerous, it can become a full-blown cancer. Just be aware that, you know, cells are reproducing all the time, very few of them will have mutations, but they do have mutations, and the thing to do is to avoid things that increase that rate of mutation.

[00:14:10] Erin Spain, MS: You both spend a lot of time with colorectal cancer patients, but you do perform other procedures and see patients with other conditions. Can you share that with me? What other types of cases do you see?

[00:14:21] Dr. Kasim Mirza: We take care of patients with both malignancies, like colorectal and anal cancers, as well as benign conditions, in the abdomen. That includes things like diverticulitis. Inflammatory bowel disease, which is on the Crohn's disease and ulcerative colitis spectrum. Other conditions that may be related to diseases outside of the colorectal and anal systems, and that may lead to obstructions of the colon or rectum, as well as complications from radiation to the bowel. And on the anorectal side, there's a lot of everyday and more common diagnoses that really can change people's lives in a big way, and that's hemorrhoids and anal fissures, cryptoglandular disease that leads to anorectal fistulas as well as pelvic floor disorders that can affect people's continence, lead to chronic constipation, as well as prolapse of pelvic organs.

[00:15:17] Dr. Jarrott Moore: It seems like a good time to point out there are actually four people in our group. There's Dr. Mirza and me, and then also Dr. Sylvia Kim and Dr. Sidney Morrison. And a simple way to think of it is that if it involves the colon, the rectum, or the anus in any fashion, then we probably deal with it, if it's surgical, for sure we deal with it. From bottom to top, the things, you know, Dr. Mirza has already mentioned hemorrhoids, fissures, fistulas, etc. Things of the anal canal. But also, I think importantly, one of the things that gets overlooked a lot, is fecal incontinence. That is something that, people are oftentimes, embarrassed about, you can even get to a point where you won't leave the house, which can be obviously life-altering, and you can miss out on things that bring you enjoyment, oftentimes people will have the assumption that they're stuck with it. This is just sort of a consequence of me aging or whatever it may be, and they're either embarrassed to talk about it with their doctors, which is understandable, or they don't think that anything can be done about it. But it is something that we can treat and we can treat quite well these days. I think it's one of the more easily overlooked aspects of colorectal surgery, and it is something that can be treated surgically, again, very good outcomes, and it can be life-changing for people who have it.

[00:16:28] Erin Spain, MS: So the last question is what we ask everyone who comes on the show and that's, what do you do to optimize your health and live well?

[00:16:37] Dr. Jarrott Moore: I'm up to date with my colonoscopies, number one. I think having a primary care doctor that you see on a regular basis, whether that's annually or more frequently, I think that's important. Primary care doctors, they're there for a reason. Think we've all either had personally having to ourselves or someone that you know who has, who thought they were in perfect health only for their primary care doctor to pick something up and, you know, thankfully pick it up before there were ever any symptoms and, you get treated. So primary care doctors are worth their weight in gold, as far as your general overall health.

[00:17:07] Dr. Kasim Mirza: I'll tell you that I'm married to a primary care doctor who's family medicine trained, and it truly is a starting point and a super important part of your daily health maintenance. Don't wait until, you know, New Year's day, start getting on a better exercise regimen, slowly start trying to cut out some of the unhealthier habits and foods keep up on your colorectal cancer screening. Seeing as this is a colorectal cancer awareness month, go out, see your primary care doctor, get referred, get your screening done.

[00:17:39] Erin Spain, MS: Great way to end the show. Well, thank you, both of you, for coming on the podcast and sharing all this valuable information. We appreciate it.

[00:17:47] Dr. Kasim Mirza: Thank you.

[00:17:49] Erin Spain, MS: For more information on this podcast, check out Advance.MUSCHealth.org. Learn more about preventing colorectal cancer as well as its symptoms, diagnosis, and treatment options.