Strong Episode 2

A dedicated father facing his second bout of lymphoma and a strong-willed man with colon cancer undergo treatment with the help of unwavering family support.

Harrison

Harrison Mullen
Colon Cancer

"If I had a colonoscopy 20 years ago, chances are I might not have been in this position."

Danni

Jed Tomczak
Hodgkin Lymphoma

"I was just afraid to go to the doctor. Nobody wants to hear bad news so you often think the worst."

Ask the Experts

Roswell Park Cancer Institute’s medical experts featured in the Cancer Can’t Win documentary “Strong” answer questions about the types of cancer and treatment recommendations that Harrison and Jed experienced.

Why is colonoscopy the best test for colon cancer?

 
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The screening options for colon cancer are somewhat varied. We have some simple tests, like testing for blood in the stool. That's a very common test. It's very easy to perform, but it's very non-specific. You could have blood in your stool for a variety of reasons other than colon cancer. One of the better tests we have is colonoscopy. It's a standard investigation and is used in patients typically over the age of 50, when we recommend standard screening for colon cancer. The reason it's a good test is because it's both therapeutic — in other words, it can take care of things if you find them — but it is also diagnostic. For example, if you have a colonoscopy and we find a polyp, that polyp can be removed and can prevent that from ever becoming a cancer. The best test is a colonoscopy and that's why it's recommended for patients starting at the age of 50. If you have a family history, sometimes we recommend colonoscopies at a younger age, but starting at age 50 it's typically recommended for most Americans to undergo a colonoscopy at regular intervals. Another screening test is virtual colonoscopy. This is a great test because it's non-invasive. It's basically done with a CAT scan. It is becoming very sensitive at detecting colon polyps. However, the issue is, if you have a colon polyp on the scan you still have to get a colonoscopy to get a biopsy and to get it diagnosed. So, the gold standard truly is colonoscopy for screening.

Joseph Skitzki, MD, FACS

The issue with the use of these tests where the stool is examined is just like Dr. Skitzki stated. There are a number of different causes of elevated blood in the stool. On the other hand, not all colon cancers bleed, so sometimes you will miss a cancer or miss a pre-malignant lesion. The beauty of colonoscopy is that if you find an adenoma, a polyp, in the colon you take it out. That polyp is out of business and that's something you don't have to worry about anymore. So, you do colonoscopy, you find something and you know it's there. If you don't see anything, there's nothing there.

James Marshall, PhD

Why is the test recommended at age 50?

 
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We're trying to get the best bang for the buck, in terms of the patients that we know that are at risk for developing colon cancer. It starts typically at a certain age group. Starting at age 50 is the standard recommendation. Only if you had a strong family history or had some predisposition to colon cancer would we recommend screening at an earlier age. But we know that the large majority of patients, if we start screening at age 50, are going to be able to be detected early and hopefully have improvement in terms of their outcomes.

Joseph Skitzki, MD, FACS

It's at age 50 that the risk of colon cancer begins to increase. That's the time when you're going to prevent the most colon cancers.

James Marshall, PhD

What can you tell about my cancer from these tests?

 
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When we do the colonoscopy, sometimes we can find polyps. They could be in various stages, from a benign polyp that may not cause any problems in the future to one that's becoming a true cancer. We're able to actually get a piece of the tissue, do a biopsy of these polyps, and tell the stage of cancer, in terms of its development and where it is at. Sometimes we're able to see some more advanced types of cancers that have gone beyond just the polyp and have become a full-blown cancer. The test is very useful because it gives surgeons the location of the tumor. It tells us in advance what kind of procedure you may require, and the best and optimal treatment that you would benefit from.

Joseph Skitzki, MD, FACS

How do you choose which drugs to use to treat my cancer?

 
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For colon cancer, there is a lot of good data. A lot of that data originated at Roswell Park in the 1970s. The data shows that there is a combination of drugs that has been proven to be somewhat effective for colon cancer. That combination of drugs has been expanded on in recent years and have become quite effective for colon cancer. We know through clinical trials, through thousands and thousands of patients who have been treated in the past, we can select the optimal chemotherapy that offers the best response for your particular tumor. We have multiple lines of chemotherapy now. We actually have certain drugs that have gone through clinical trials that are more specific for colon cancer and that are less toxic. We have pills now that are orally available so that patients can take the chemotherapy at home. There are a lot of decisions that go into choosing which drug is the best, but now, in the year 2013, we have a lot of options compared to what we had in the past.

Joseph Skitzki, MD, FACS

Increasingly, what we're doing, is looking at the genomic structure of any cancer. In this era of what's called personalized medicine, we can decide which drug would be most effective based on the genomic structure of that tumor. That's been a dream of ours for a long time, but it's coming to fruition.

James Marshall, PhD

What happens if my cancer spreads to another area of my body?

 
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Colon cancer can spread in a variety of different ways. One of the typical ways that colon cancer can spread is to the lymph nodes, in that area. Usually at the time of surgery, we are very particular to take out those lymph nodes. If they are found to be positive — in other words, if the cancer has spread to those lymph nodes — we would recommend further treatment usually in the form of chemotherapy. However, we know that colon cancer can spread to other places through the bloodstream. For example, it can spread to the liver. It's a very common site for colon cancer to spread to. In the past, there weren't a lot of options for colon cancer when it spread to the liver. But now, with a more aggressive surgical approach, we have found that, if the lesions — in other words, the tumors that have spread to the liver — can be removed safely without removing too much of the liver, we can actually extend survival significantly in those patients. In recent years, we've taken a much more aggressive approach to removing any evidence of colon cancer spread, especially in patients that have limited disease. In other words, they only have one or two tumors in their liver. The same applies for the lung and for tumors that may spread through the lining of the abdomen. We've been becoming more and more aggressive in terms of our approach to advanced stage colon cancer. It's showing that we are able to improve survival and there is a true benefit for being aggressive.

Joseph Skitzki, MD, FACS

One of the tremendous advances we've made over the past 15–20 years is that people with disseminated disease are still alive. It doesn't happen as often as we would like, but we are able to control those cancers, in many cases.

James Marshall, PhD

Can my cancer still be treated if it spreads?

 
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Particularly in a place like Roswell Park, where we're treating some advanced stage patients, there are a lot of treatment options available here that may not be available elsewhere. For example, we talked about colon cancer and how it can spread to the liver. We're very aggressive in terms of dealing with disease that has spread to the liver, to the lung, etc. But we're also very aggressive in disease that has spread to the peritoneum, and that's the lining of the abdomen. For example, 10, 20 years ago, when you had peritoneal spread — in other words, carcinomatosis — from colon cancer, it was deemed uniformly fatal. We have found that in select patients, who have limited disease, an aggressive surgical approach where we're able to give chemotherapy directly to the abdomen may actually offer some good benefit. To the point where, if you can remove all the disease you can see and then treat with chemotherapy to clean up any other residual disease, we know that one out of three of those patients can be cured long term. And that's quite an improvement over being an almost uniformly fatal disease.

Joseph Skitzki, MD, FACS

How do I find out if a clinical trial might be a treatment option for me? What if I change my mind after enrolling?

 
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The way we learn more about how to treat cancer, the best way to learn, is to perform clinical trials. There's simply no other way, other than to try different combinations and to ask people to participate in clinical trials. It's important that we insist, when we allow a patient to join a clinical trial, that we make very sure he or she understands exactly what it is we know and what it is that we hope to find out. Patients' rights are vigorously protected during clinical trials and if a patient joins a clinical trial and decides to withdraw, the patient has every right to do that at any point in time. This is how we learn and we ask people to help us figure this out. In some cases, it will help the patient. In other cases, it may not help the patient, but it will help us as we go down the road and try to figure out better ways to lick this disease.

James Marshall, PhD