John L. Marshall, MD: Hello, and welcome to this OncLive^® Peer Exchange^® panel discussion titled “Evolving Strategies for Advanced Colon and Rectal Cancer.” Now more than ever, we are witnessing improvement in both long‐term survival and quality of life as our management strategies for patients with advanced colorectal cancers continue to evolve rapidly. I am joined today by a group of experts in the field of gastrointestinal oncology. Together we will examine the research presented at the 2018 ASCO Annual Meeting. We’ll talk about how these new data may shape the way we manage advanced colorectal cancer in the clinic.

I am Dr. John Marshall, chief of the Division of Hematology/Oncology at MedStar Georgetown University Hospital, professor of medicine and oncology at Lombardi Comprehensive Cancer Center of Georgetown University, and the director of the Otto J. Ruesch Center for the Cure of Gastrointestinal Cancers in Washington, DC. And our faculty begins with Dr. Gabriela Chiorean, clinical research director of gastrointestinal medical oncology at the University of Washington Medical Center, associate professor of medicine at the University of Washington School of Medicine, and medical oncologist for the Seattle Cancer Care Alliance in Seattle, Washington. Gabby, welcome.

Gabriela Chiorean, MD: Thank you.

John L. Marshall, MD: Second and next to me on this side, Dr. Marwan Fakih. Did I do it right?

Marwan Fakih, MD: You did.

John L. Marshall, MD: Next to me on this side, Dr. Marwan Fakih, professor of medical oncology and therapeutics research, medical director of the Clinical Research Unit, and section head of GI Medical Oncology at the City of Hope Comprehensive Cancer Center in Duarte, California. Marwan, welcome.

Marwan Fakih, MD: Thank you.

John L. Marshall, MD: Next, Dr. Bert O’Neil, over there, professor of medicine, Joseph W. and Jackie J. Cusick Professor of Oncology, and director of Phase I & GI Oncology Programs at the Indiana University School of Medicine in Indianapolis, Indiana. And Dr. Wells Messersmith, professor and head of the Division of Medical Oncology, coleader of the developmental therapeutics program, and associate director of Translational Research at the University of Colorado Cancer Center in Aurora, Colorado. Thank you, guys, so much for joining us. Let’s get started.

Gang, so just a couple of days ago there was an announcement that they’ve changed the screening guidelines for colorectal cancer, moving it earlier to 45, later to 85. Anybody want to tell me why we did this? Bert, what happened here?

Bert H. O’Neil, MD: Well, my understanding is the American Cancer Society looked through their data, I’m not sure for what time period, but came to the conclusion that there has been a real increase in incidence of colon cancer in people under 50. So the shift was there. I think this is something, I feel like I’ve noticed, although it’s always hard when you’re in an academic center to know what’s referral bias versus a real trend. But I think this is probably a real thing.

John L. Marshall, MD: Is everybody seeing this? Is everybody seeing younger patients in your clinic?

Gabriela Chiorean, MD: Absolutely. We even see teenagers with newly diagnosed disease, especially the distal colorectal cancer, rectal, and then sigmoid colon. It’s a very perplexing situation because we don’t really know what’s causing this.

John L. Marshall, MD: Yes, is this Starbucks coffee, is it cell phones? What’s going on? Why are these young people getting …?

Marwan Fakih, MD: Coffee is supposed to cut down the risk of cancer.

John L. Marshall, MD: Oh, that’s right, coffee is good. Thank goodness.

Marwan Fakih, MD: I think we’re seeing the same alarming trend as well in our practice, not only 40s but definitely we’re seeing 30s. I’m not really sure if it’s the body mass index, certainly the lifestyle changes. People are frankly more obese. But what is also alarming is that we see some fit patients who come to our practice in their 30s and 40s who have rectal sigmoid cancer, and there’s no significant family history. You do the genetic workup, and you don’t find anything. So, my understanding is there has been a rise of almost about 1% per year in the past decade or two in colorectal cancer in patients less than 50. So this is, I think, overdue. I think this is a good thing to be able to offer screening earlier.

John L. Marshall, MD: Yes. My patients tend to be not obese. They’re the fit, healthy exercising group. I sort of joke that they’re the marathon-running, cardboard-eating people who are all of a sudden showing up, and they are in their 20s and 30s. So, does moving this to 45 do any good?

Wells A. Messersmith, MD, FACP: I’m not sure. I think if anything it will increase awareness. I think one of the issues with younger people, both the patients themselves and their medical providers, is that they have symptoms that, as a physician, we consider worrisome, such as rectal bleeding or change in bowel habits, and they’re told, “Oh, you’re too young to have colorectal cancer. This is just a hemorrhoid; don’t worry about it.” And so, I think in the younger patient population, there’s often a pretty harmful delay in diagnosis. I’ve seen younger people, and I agree, we’re seeing more and more of these younger patients who have had symptoms sometimes for years and really haven’t been taken seriously because the level of suspicion was so low. If anything else, this will raise awareness. Colonoscopy, it’s a reasonable test, it’s expensive, it’s invasive, and barely over half of Americans get it according to the guidelines.

John L. Marshall, MD: It doesn’t really fit what a screening test is meant to be.

Wells A. Messersmith, MD, FACP: Exactly.

John L. Marshall, MD: Cheap and noninvasive, and it certainly is neither of those.

Wells A. Messersmith, MD, FACP: Yes. So, I think the most exciting data that have come out recently are some of these blood-based markers and other things that screen not only for colorectal cancer but for a whole bunch of cancers noninvasively and cheaper. And I think that’s really where we should be putting our resources.

John L. Marshall, MD: Yes, the president and I tweeted out sort of the same thing, that I’m unhappy about this. I think this is sort of throwing a bone to the problem, and what I think we need is investment in research to figure out why these people are getting it, because it will pick up a few more people, but it’s not going to pick up that teenager, the 20-year-old, the 30-year-old. I agree totally with the awareness, but we really need to study this and figure out what’s going on. My hope would be that what we learn from this group of people, if we can actually figure out what’s inciting all this, that we would learn new biology about colon cancer and maybe effect screening overall. Fingers crossed on that.

Transcript Edited for Clarity