Minimally Invasive Surgical Approaches Are a Convenient and Effective CRC Management Option

The colorectal cancer (CRC) treatment paradigm has expanded to include minimally invasive surgical approaches, such as laparoscopic surgery, that can add ease and convenience to the management of a disease that is growing increasingly prevalent in younger generations of patients, according to Andreas M. Kaiser, MD.

“If [a patient] has symptoms of, for example, bleeding or changes in bowel habits, they should [reflect on their diet or lifestyle habits],” Kaiser explained in an interview with OncLive® during CRC Awareness Month, observed in March. “Ultimately, they should [undergo] an evaluation and not just [assume they have] hemorrhoids, because, unfortunately, sometimes that’s not the case.”

In the interview, Kaiser highlighted the importance of spreading knowledge about this disease during CRC Awareness Month, minimally invasive surgical approaches that are currently part of clinical practice for patients with CRC, and how these approaches may differ between community and academic settings.

Kaiser is a professor and chief of the Division of Colorectal Surgery in the Department of Surgery at City of Hope in Duarte, California.

OncLive: Why is it crucial to spread awareness about the prevalence of CRC during CRC Awareness Month?

Kaiser: CRC can occur frequently and can affect any one of us; no person is protected [from the disease because] it develops at random. In some patients, [its development] is predictable because they have a genetic predisposition. However, beyond that, it is important to understand that we could prevent CRC development if we look early enough.

Over the past 30 to 40 years, the incidence of CRC has overall decreased. However, we see an unfortunate accelerating trend nationally—and maybe internationally—of the disease occurring in younger generations. What was a disease of 60-to-70–year-olds in the past has now become a disease that affects 40-year-old, 30-year-old, and 20-year-old patients. We’re [now starting to] see cases where young women come in [for CRC screening] after pregnancy. They’re all of a sudden diagnosed with cancer—sometimes very advanced cancer—and it breaks our hearts, but that’s where we need to step in and address [their disease].

We also need to take the opportunity of CRC Awareness Month to clarify [information regarding screening]. In the United States, an average-risk individual with no family history or symptoms [of CRC] should start screening at 45 years of age. However, people with symptoms or additional risk factors should undergo colonoscopies [at much earlier ages].

How have advances with minimally invasive surgery affected the CRC treatment paradigm?

We sometimes meet patients [who tend to be older] and have a landscape of scars on their abdomen. These tend to be 6-to-10–inch scars from gallbladder surgeries or appendectomies, but those 2 organs are only approximately 3 inches each. Nowadays, we can take out a 5-foot organ, such as the colon, entirely through an 8- or 12-mm incision.

That’s the difference [between open surgery and minimally invasive surgery: with minimally invasive approaches], we can do all the work internally—including resecting and connecting the bowel—and we only need to make an opening somewhere [on the abdomen] to retrieve the organ once it should be removed from the body. That prevents the bowels from becoming traumatized by being exposed. [During open surgery], the bowels could dry out and become aggravated. Therefore, when we can use a minimally invasive approach, we can protect the environment for the bowels. With this approach, [we may] also see the bowels propulsing [their contents], and that typically doesn’t happen with a major incision.

Still, a major incision is not wrong in certain circumstances. For patients who have undergone previous surgeries—including previous [unsuccessful] surgeries—sometimes a big, open surgery is the right approach.

The use of robotic surgery is increasing for the management of multiple tumor types. What are some of the challenges associated with adopting robotic surgery in CRC, especially in the community vs academic setting?

There are several obstacles that come up. The most important one is proper training and skills. General surgeons have always tried to manage patients with CRC, but the reality is that [colorectal surgery has] become a highly specialized field. If patients experience a condition that affects those organs, they should probably [receive treatment at a center with] high specialization, such as City of Hope or other bigger centers. Academic centers also have less of a generational divide [compared with community centers]. [Many] young surgeons who come out of training are doing more specialty training, and it keeps the whole environment fresh. We need to prove to ourselves that [our field is] still up to date. [This also allows us to] reassess whether these approaches are valid or whether we need to go back to the old approaches. That’s one of the advantages of [receiving colorectal surgery] an academic center.

[Another obstacle is] the cost of buying equipment. For example, the cost of a robot is quite high, but a bigger center with 60 faculty members who will use that machine will pay it off [relatively quickly]. [However, at a center with] only 1 or 2 [surgeons] who might occasionally do a case, then many times, the robot or laparoscopy equipment is not appropriate and would take a much longer time to pay off. In general, it’s possible to do robotic surgery in the community setting, but the know-how is concentrated at bigger centers.