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Interviewer: Figuring out the best colorectal cancer treatment option for you. That's next on The Scope.

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Interviewer: Dr. Courtney Scaife is a surgeon that specializes in gastrointestinal oncology and is also an expert in colorectal cancer treatments at Huntsman Cancer Institute. I was doing a little bit of research on colorectal cancer treatment options and I've got to tell you, Dr. Scaife, it's overwhelming. There are a lot of different options. I can't even imagine somebody's who has just been diagnosed that's trying to parse through all these different options on their own what they're facing. Help me make sense of that.

Dr. Scaife: There's no question that the information available on the Internet, on public institutional venues and so on is overwhelming. Doing research, investigating your diagnosis before you see your doctor is useful, but if you haven't had your diagnosis narrowed down exactly what is your diagnosis and what is your stage, that information can be very, very overwhelming. To some extent, knowledge is power, but when it becomes overwhelming, it's helpful to wait until you meet with your physicians and get your diagnosis and your staging narrowed. But that information can be whittled down into a package that's more tolerable.

Interviewer: Yeah, I think I scrolled through six, seven pages of a bunch of words that made no sense to me. After you get your diagnosis you said the two key things are your stage . . .

Dr. Scaife: Correct.

Interviewer: . . . and what's the other one?

Dr. Scaife: Your stage and your diagnosis. Colorectal cancer is a term that we group together. Colorectal cancer, it is one disease, but the distinction is the anatomy or where the tumor is located in the body. Because of the anatomy of the rectum, which is the farthest down or the lowest part of your colon, the anatomy of that is a little bit different than the colon so we treat rectal cancer, which is a sub-type of colon cancer, just a little bit differently.

The first thing we decide is does someone have rectal cancer or do they have colon cancer. Then, we decide what stage is it or what is the preliminary staging that helps us look at the treatment plan from there.

Interviewer: Help me walk through some of this process when you do have a patient in your office. They would go through some tests. You would determine the stages. You would determine the type of cancer. What do you do at that point to determine the treatment option that's best for them?

Dr. Scaife: Well, the most common scenario is that someone's had a colonoscopy. Either they had symptoms or they're in their routine surveillance, which should be everyone at the age of 50 and then every five to 10 years after that. If something was found, a concerning polyp, a precancerous high-grade dysplastic polyp is what it's called, or a cancer, then the next thing we do is stage that.

We do the staging by getting a CT scan of the chest, the abdomen and the lower abdomen that we call the pelvis. If we are sure that there is no evidence that, that cancer in the colon has tried to spread to other organs, specifically the lungs and the liver, the most common, that would make it a stage IV if it has spread to other organs. If it has not it's a stage I, II, or III.

That stage is determined by are any of the lymph nodes involved, which would be a stage III, or how thick has the tumor tried to go through the wall of the colon, which would distinguish a stage I, II or an advanced stage III. Those things we often don't know until after a surgery.

If you have rectal cancer, we do further studies to try to help to find those stages first. If you have colon cancer, surgery is the first treatment and that stage is determined at surgery. Already, you can see that the distinction between colon cancer and rectal cancer starts making those decision trees very different. Interviewer: What are some common questions that patients ask in that consultation with you after you've determined the type of cancer and the stage?

Dr. Scaife: The most common question is, "When can we get this taken care of?" Obviously, as soon as possible. We'll do everything we can to do that as soon as possible. The next most common question is, "Will I need chemotherapy?" We don't know the answer to that until after we've decided if it's rectal cancer, most commonly. We often do use chemotherapy. If it's advanced stage II or stage III colon cancer, then it will get chemotherapy after surgery, but surgery would be first.

The third most common question is, "Will I need a colostomy? Will I need a bag to poop in?" Unless it's a low rectal cancer or a really worrisome, very, very large left-sided or more distal in the colon, colon cancer, it's really uncommon to need to have a colostomy bag.

Interviewer: Are there often, after that point, different ways that you can approach the treatment that the patient might have to make the decision, "I would rather do treatment A or treatment B?"

Dr. Scaife: Yes and no. Most commonly, that comes if we have a clinical trial. An important point is that a clinical trial is only ever available if we think that the investigative arm is most likely to be a better option than the standard of care.

Some patients are very scared of trials, but we can't write a trial and IRB wouldn't approve a trial if we didn't that the trial arm is probably actually better than what is the standard of care. If a clinical trial is available, then we give patients the option do they want to be involved in the trial or not.

Otherwise, for colon cancer, really surgery is the first option. Then decisions of do they want chemotherapy after the surgery if they're a stage II or a stage III. In rectal cancer, decisions about do you want only chemotherapy before surgery. We do chemotherapy and radiation often before surgery in rectal cancer. Do they want chemotherapy only? Do they want chemotherapy and radiation before surgery? Do they want a short course of radiation or a longer course of radiation? All of those decisions are decisions that patients participate in but based on the advice of the medical oncologist, radiation oncologist, and surgical oncologist.

Interviewer: What tends to be done most often, it sounds like, is surgery.

Dr. Scaife: Correct. Again, for rectal cancer, it's very common to get chemotherapy and radiation before surgery, but the treatment for either colon or rectal cancer is surgery.

Interviewer: What are some of the other considerations that a patient should keep in mind as they're going through this conversation, as they're sorting through what options they might have? What would you want them to keep in mind?

Dr. Scaife: Definitely the most important thing to do in getting ready for a treatment for colon cancer surgery and possibly chemotherapy is really to just be healthy. There's a big push across the country. The University of Utah and Huntsman Cancer Institute have a huge push right now to really emphasize pretreatment health.

Minimize or stop, ideally, your smoking. Control your diabetes really well. Control your other medical problems, your high blood pressure. Try to exercise three or four times a week at least 30 minutes those three or four days a week. Try to eat a well-rounded, healthy diet. There's no special diet that can prevent or cure rectal or colon cancer, but just a well-rounded, healthy diet really strengthens a patient to get through surgery and other treatments that are necessary.

Interviewer: That's kind of nice. Somebody could take control of those things right away before they know anything else about their cancer.

Dr. Scaife: That's exactly right. There's actually data now that shows that people that exercise before and after colon cancer surgery decrease their risk of recurrence.

Interviewer: Do people that tend to have colorectal cancer have time to get in shape before the surgery? Are we talking about they would have three or four weeks that they could stop their smoking? Is it a slow-moving cancer that they're allowed that luxury?

Dr. Scaife: Yes and no. The answer is yes, there usually are two to three weeks. It is a very slow moving cancer. Two to three weeks, five to six weeks won't make a difference in the outcome of the cancer. Sometimes even longer.

But the other side to the answer of your question is that even just two days is beneficial. For a smoker, just not smoking for two days before an operation makes a really, really big difference. For a person who's relatively sedentary to just go out for a 30-minute walk three days a week for just the two days before your operation can already make a difference.

Interviewer: It sounds like wait until you find out the type of cancer and the stage before you start freaking yourself out with all the options. Let your physician or your cancer team help narrow those down for you. It sounds like surgery is going to be kind of the first thing and then some other decisions will have to be made after that point and get out and exercise right now in preparation for any treatment that you might get. Is there anything else that you would tell a patient at this point as they're leaving your office because I imagine it's an emotional scary time for them?

Dr. Scaife: After the diagnosis has been made and you're leaving your doctor's office, as you said, this information is overwhelming from the beginning. But now that you know is it colon or rectal cancer and you know what stage it is, I, II, III or IV, now you can start to find out specific information.

Asking your doctor what questions to ask, where to get the information. One of the most valuable resources is the Cancer Learning Center at Huntsman Cancer Institute. It's one of the biggest, I think it is the biggest, patient cancer centered library in the country. They have librarians trained to teach people how to get the resources in their diagnosis, in their family situation and in their social network and their questions that they have. The librarians can help them get educational materials appropriate for their diagnosis.

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Dr. Miller: You've been told that you might need a Whipple. What does that mean? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, here with Dr. Courtney Scaife. She is a professor of surgery here in the Department of Surgery at the University of Utah. And she also specializes in cancer surgery. Courtney, what is a Whipple?

Dr. Scaife: A Whipple is an operation on the pancreas when you have a neoplasm, which can be a mass or a tumor or a cyst, those are all synonyms, in the proximal part or we call it the head of your pancreas. And the Whipple removes that part of the pancreas.

Dr. Miller: So the Whipple is the name of the type of surgery that you do. Is that pretty typical as pancreatic surgery goes?

Dr. Scaife: That's correct. Well, the Whipple is the only surgical procedure of the pancreas that's named after the doctor who first described the operation. Other pancreas surgeons are often more anatomically referenced, such as a distal pancreatectomy or an enucleation of a tumor out of the pancreas.

Dr. Miller: So Whipple has been a surgery that's been practiced for many years, I think. Is that right?

Dr. Scaife: Dr. Whipple first described the operation in the 1950s. And as first described, it was a two-day operation where the pancreas was taken apart, and the next day, everything was put back together.

Dr. Miller: My understanding is that Whipple surgery is a curative surgery for some patients with pancreatic cancer.

Dr. Scaife: That's correct. So again, Whipples are done for all types of neoplasms. And again, neoplasms can be masses, tumors, cysts in the pancreas. And so a Whipple for a non-cancerous neoplasm is obviously curative. And a Whipple for pancreas cancer can also be curative.

Dr. Miller: If one has a pancreas cancer and they're going to undergo Whipple, the purpose of that would be to cure the cancer, I think, obviously, right?

Dr. Scaife: Yes.

Dr. Miller: And once that takes place, what can the patient expect after a Whipple surgery?

Dr. Scaife: So a Whipple operation is complex. It's a six- to eight-hour operation.

Dr. Miller: That's a big operation.

Dr. Scaife: Yeah. And because of the location of the head of the pancreas intimately involved with the bile duct and the first part of the small intestine, we have to rebuild all of those. So we rebuild the pancreas. We rebuild the first part of the small intestine. And we rebuild the bile duct. But in the end, the patients can eat normally. They can eat any food they like. And they do quite well after recovering from the operation.

Dr. Miller: Is there anything that you tell your patients in that preoperative period when you first meet them before they undergo the surgery?

Dr. Scaife: We frequently tell patients that the surgery, again, takes six to eight hours. They'll be in the hospital for approximately seven days. For a month after a big surgery like this, their appetite, their energy, and their strength will all be much lower than they normally expect. And it usually recovers four to six weeks after surgery.

Anything someone has before surgery gets a little bit worse and harder to manage after surgery. So diabetes, high blood pressure are all a little bit harder to manage after a big operation like this. But it recovers about a week or two after surgery and goes back to their baseline.

Dr. Miller: So that's interesting. Do you use a team approach with another physician such as an internist to help manage the patient after the surgery if they have diabetes or other complications?

Dr. Scaife: Generally we manage it on our own. Because they're short-lived, we're able to manage it on our own.

Dr. Miller: Do they ever experience diarrhea following pancreatic surgery? Is that something that they need to worry about?

Dr. Scaife: Yeah, chronic diarrhea after a Whipple operation is extremely uncommon, but not zero. Some patients get dumping syndrome, which happens in less than 10% of our patients.

Dr. Miller: What is that? What's dumping syndrome?

Dr. Scaife: It's from operating on the stomach and re-plumbing it effectively to the small intestine or rebuilding that first part of the small intestine. Some patients can have a syndrome where they eat rich foods, and the foods go through the stomach. And the next part of the small intestine, it's not used to seeing such rich foods, reacts by pouring a lot of water into the intestine.

And that neurologic response can result in almost like a hot flash-type symptom. And then after all of that water gets emptied into the intestine, 30 to 60 minutes after a meal, patients can have diarrhea from the water flushing through their system.

Dr. Miller: Now, generally, that resolves in a couple of weeks? Or does that continue?

Dr. Scaife: In 10% of our patients, after the Whipple surgery, they experience that. Fewer than 1% of the patients have a long-term problem with that. It normally resolves on its own and the few patients that it doesn't, learn to eat around it so they don't stimulate those symptoms.

Dr. Miller: So over time, people who have a Whipple procedure, they potentially are cured of their cancer. Do they end up keeping the same weight that they had before? Do they lose weight after a Whipple where part of the pancreas is taken out? And as I understand it, the pancreas is very important in digestion.

Dr. Scaife: That's right. So the answer to the first part of your question is that most of our patients, 80% of our patients, do well and maintain their normal appetite, normal diet, and normal weight. We do have different ends of the spectrum, obviously. There are some people who gain weight and some people who don't eat as well after the operation, but that's very unusual.

The second part of your question, the pancreas does two things. It manages your blood sugars and it helps you with digestion. And so after we remove part of the pancreas, it's very uncommon to cause someone to be a diabetic from a pancreas surgery. You only need 10% of a normal pancreas to manage your blood sugars normally. So very few people become diabetic as a result of the operation.

Dr. Miller: So you're not taking out the entire pancreas during the Whipple.

Dr. Scaife: Correct, correct. And really about a third to only 20% of the pancreas comes out with the operation.

Dr. Miller: Now, this is a big operation, as you've outlined. Do patients experience much pain postoperatively or in the several months following surgery?

Dr. Scaife: No, we're really able to manage the pain very well. We use local anesthesia in the incision or an epidural in the postoperative care. And then patients actually recover quite well in usually one to two weeks out from surgery. They're off of any pain medications and starting to resume their normal activities and functions.

Dr. Miller: Can you give us a wrap-up about who comes to you for potential surgery?

Dr. Scaife: Most of our consults for pancreas neoplasms are simple cysts or benign cysts in the pancreas. And so 80% of our patients don't need an operation, even though they're referred to us for evaluation. Of the few that do need an operation, those patients do extremely well. They don't all need Whipples. There are other less invasive operations of the pancreas that can be done. And all of those patients, including the patients who do Whipples, ultimately return to a very normal lifestyle.

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Dr. Miller: You have Barrett's Esophagus? When do you need surgery, or do you even need surgery? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.
Dr. Miller: We're here today with Dr. Courtney Scaife and she's a Professor of Surgery here in the Department of Surgery at the University of Utah. She also specializes in cancer surgery. Courtney, tell us a little about a patient who might need surgery on the esophagus. I understand that patients with Barrett's Esophagus mostly don't need surgery, but there are times when they do. When would that time be?

Dr. Scaife: Patients who have Barrett's Esophagus are usually managed by gastroenterologists. And they're well managed with oral medications or sometimes requiring interventional procedures. But if that Barrett's progresses to high-grade dysplasia or an invasive cancer, high-grade dysplasia is a pre-cancer change to the cells in the esophagus. So if a patient has pre-cancerous changes that can't be managed by the gastroenterologist's limited interventions, meaning limited intervention to the esophagus or they've regressed to full cancer, those patients do need a surgery of the esophagus.

Dr. Miller: Now, that's not typically common in Barrett's but it does occur.

Dr. Scaife: That's correct, it's uncommon.

Dr. Miller: So by the time the patient gets to you, they usually have advanced Barrett's or adenocarcinoma of the esophagus that isn't remedial by any of the topical treatments that the gastroenterologists use.

Dr. Scaife: That's correct.

Dr. Miller: And so what do you tell the patient initially and what can they expect undergoing surgery?

Dr. Scaife: The first thing that is important to evaluate is if they progressed to cancer, but it's a very early stage, they need the surgery we're talking about. If they have a slightly later stage or more advanced cancer, we routinely treat those patients with radiation and chemotherapy before surgery. There are actually two types of cancer of the esophagus, two different cellular types. And one is more likely caused by smoking, the other is the kind, adenocarcinoma that is related to Barrett's and chronic reflux. And we do treat that in more advanced stages with neoadjuvant, meaning treating the patient with chemotherapy and radiation before surgery. Therapy.

Dr. Miller: Patients can develop Barrett's Esophagus after many years of esophageal reflux or acid reflux or otherwise known as heartburn. And so if you have heartburn and you've had it for five years or over the age of 50, you should see your primary care physician to have that treated and possibly looked at by a gastroenterologist.

Dr. Scaife: Yes, we agree. And screening in patients who have chronic reflux is important to identify Barrett's and to monitor that Barrett's does not progress to those pre-cancerous or cancer changes.

Dr. Miller: Now, removing the esophagus, or otherwise known as an esophagectomy, sounds like a pretty big surgery. What would a patient expect, following that?

Dr. Scaife: It is a big surgery and, unfortunately, there are several different ways to do the operation. The operation can be done through the abdomen and the neck, it can be done through the abdomen and the chest, or it can be done through the abdomen, the chest, and the neck. And then minimally invasive techniques can be added as well. And so many surgeons use different techniques. But really there's no data that shows that either approach is different. And you want the surgeon to do the operation that they are most comfortable with and that they do that operation most frequently. But all of the techniques of the operation, the outcomes are effectively the same.

Dr. Miller: Does it at all depend on the type of patient? Their size, their body physiology? Does that sway you in terms of the type of surgery that you do if their large, small, or . . .

Dr. Scaife: Usually not. There may be some unusual cases where that influences the decision, but usually not. When we do esophagus surgery, we don't just take out a piece of the esophagus. Particularly in this case because it's for cancer. So we need a wide margin around the cancer. So effectively the patient's entire esophagus is removed. So in that approach, and the reason that all of those approaches included an abdominal portion of the surgery, is that we need to choose a part of the abdomen, another part of the intestinal track to replace the esophagus.

Dr. Miller: So it's like a graft.
Dr. Scaife: That's exactly right. So the choices most commonly are the stomach, a piece of the small intestine or the piece of the colon. And I would say, in 2015, the most common approach is to use the stomach as a replacement for the esophagus.

Dr. Miller: Do you need to use the whole stomach or part of it?

Dr. Scaife: Yes, so in order to get the stomach to reach up into the neck, to reach where you're replacing the esophagus, it's as though they've had a stomach removal or almost like a gastric bypass surgery. So their stomach is made to be a very narrow tube and pulled up into their chest so effectively they don't have a reservoir to store their meal. And so patients eat four to six frequent small meals a day instead of eating Thanksgiving dinner.

Dr. Miller: And so do they tend to lose weight in the long run?

Dr. Scaife: Fortunately, we're able to train patients to eat really well. The majority of patients that we operate on, having so many symptoms before surgery that they admit they've been eating that way before surgery. So most patients do not lose weight and actually do well after surgery.

Dr. Miller: Now, Courtney, you mentioned that there are two types of cancers encountered in esophageal cancers, and I think one is above and one is below. Does that affect the type of operation that you do?

Dr. Scaife: It does. If we frequently . . . squamous cell carcinoma, we've been mostly talking about adenocarcinoma of the esophagus.

Dr. Miller: Squamous cell is more associated with smoking and alcohol.

Dr. Scaife: That's right. So Squamous cell carcinoma more associated with smoking is frequently more in the more proximal, closer to your mouth part of the esophagus. Sometimes that can be treated with chemotherapy and radiation only. If it persists after the chemotherapy and radiation, we do an esophagectomy. And often that procedure necessitates opening the chest to get an appropriate section of the higher part of the esophagus.

Dr. Miller: Now, following a successful surgery, I imagine that one needs to go back in and look from time to time to make sure there are no complications. Is that true?

Dr. Scaife: We ask patients in their frequent clinic visits which, at minimum, are every six months, if patients are having symptoms with swallowing, symptoms with eating, weight loss or weight gain as you've mentioned, diarrhea, but most commonly, it's difficulties with swallowing or weight loss. If those patients are having symptoms, we refer them to a gastroenterologist for an endoscopy to evaluate the graft that we used to replace the esophagus.

Dr. Miller: So it sounds like the best way to keep from ending up in the office of the surgeon is to avoid smoking altogether, to drink minimally if you drink at all. And also, if you have acid reflux and are over the age of 50, to have that looked at.

Dr. Scaife: That's exactly right. And we recommend that if you have long-term reflux to have at least one screening and then follow up based on the recommendations of your gastroenterologist.

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