Colorectal Cancer Management Requires Multidisciplinary Approach

James W. Fleshman Jr, MD

Determining the best way to treat patients with colorectal cancer is not a simple task. Technology has expanded surgical methods; laparoscopic surgery, robotic surgery, and other advanced techniques now offer less invasive procedures. In addition, the treatment of colorectal cancer has evolved from the responsibility of one or two specialists to an entire multidisciplinary team, improving outcomes for patients.

In an interview with OncLive, James W. Fleshman Jr, MD, from the Department of Surgery and Internal Medicine at Baylor University Medical Center in Dallas, explained how technological advances and a growing commitment to a multidisciplinary approach have impacted the treatment of colorectal cancer.

OncLive: How does a tumor’s location impact the surgical treatment and long-term outcomes for patients with colorectal cancer?

Fleshman: Colorectal cancer is influenced by its blood supply and by the position that the cancer has along the length of the colon. Rectal cancers are a little bit more difficult to treat. We now have multiple options that are available to us. We use multimodality therapy for rectal cancer. It lives in a boney box, which inhibits a purely surgical treatment for rectal cancer. Therefore, we use chemotherapy and radiation; patients with rectal cancer can have a sphincter-sparing operation to hook them back together and can continue to have normal bowel function.

However, there are a certain number of patients who end up with a permanent ostomy because the tumor is so low in the rectum and the muscles in the pelvic floor are involved. On the other hand, colon cancer that is located anywhere along the rest of the colon from the sigmoid to the right colon is treatable primarily with an anatomic directed resection. That can be accomplished through open, laparoscopic, or robotic methods. Following the major blood supply is the most important feature for doing a complete resection of colon cancer.

What are the benefits of a multidisciplinary approach?

A multidisciplinary approach for colorectal cancer is now considered the standard of care. We have a multidisciplinary team that meets every other week to evaluate and discuss all of the patients who come here for treatment of colorectal cancer. The multidisciplinary approach to rectal cancer in Europe has actually improved the outcomes for patients there, so now their survival is better than the patients that have colon cancer. That is a complete reversal of outcomes.

Our multidisciplinary team is made up of medical, radiation, and surgical oncologists; surgeons; colorectal surgeons; radiologists; gastroenterologists; genetic counselors; and anyone else who touches the patient. The idea is that we follow processes that are protocolized. Patients are presented to the multidisciplinary team, options are developed, recommendations are made, follow-up is based on guidelines, and we move forward.

A multidisciplinary team is probably the most effective way to treat any cancer and I anticipate that, in the future, it will no longer just be used in colorectal cancer. Every solid tumor that we have will have a multidisciplinary team wrapped around it and those patients will end up with a better outcome.

What is the role of laparoscopic and robotic surgery in colorectal cancer?

The surgical management of colorectal cancer is mostly influenced by its position in the colon and the rectum. However, as capabilities arise and surgeons have better technical skills, we have turned to a minimally invasive approach. Laparoscopy is less invasive than open surgery, and robotic is another method of doing a minimally invasive surgery.

We think that the short-term outcomes of any minimally invasive approach will actually benefit the patient in their long-term treatment. They get to chemotherapy faster, they have less down time, and their immune suppression is less with a minimally invasive approach. Patients who have smaller incisions have less pain, require fewer narcotics, and have less of stress response to the operation. We think it really does impact their long-term outcome.

What advances have been made in treating liver metastasis?

The tumor that has spread to the liver in the otherwise healthy patient with primary, resectable colorectal cancer is probably the most controversial area of our specialty right now. Patients present with a liver metastasis that is immediately resectable at the time of the resection of the primary tumor should likely undergo a simultaneous approach to both processes.

However, someone with a wide spread metastasis of the primary colorectal cancer, probably should go straight to chemotherapy to reduce the tumor burden and then consider the impact of the primary lesion and the liver lesion on the quality of life. We are hoping that we can turn stage IV colorectal cancer into a chronic disease as opposed to having a terminal disease. Chemotherapy in different levels and molecular profiling will likely help us establish the treatment plan that we need for those patients who present with an advanced stage.

What are a surgeon’s options for treating liver metastasis?

The team at our institution now has multiple modalities available for treating liver metastasis. Options include the Gamma Knife, radiofrequency ablation, wedge resection, and formal segmental resection. We also have used ex-vivo resection and replantation of the liver to remove the entire tissue burden. If you have a patient who is difficult to manage, we have been able to find some approach that will give them short-term, if not long-term, capability for outcomes.