- [Announcer] "Conversations for the Common Good" is underwritten by Geisinger College of Health Sciences.

Research and education for a new generation of learners.

WVIA, in partnership with Geisinger College of Health Sciences, presents "Conversations for the Common Good".

Colorectal cancer, prevention, treatment, and a path forward.

And now, moderator, Tracey Matisak.

- Hello, everyone, and welcome to "Conversations for the Common Good," Colorectal Cancer, Prevention, Treatment, and a Path Forward.

I'm Tracey Matisak.

Every year, roughly 150,000 Americans are diagnosed with colorectal cancer.

It's the second leading cause of cancer-related deaths for men and women combined, taking more than 50,000 lives every year.

Here in Northeast PA, colorectal cancer rates are notably high, higher than the national average.

While colorectal cancer rates have been slowing among older adults, they've been rising steadily in adults under age 50.

Over the next hour, we'll explore what's behind this disturbing trend.

We'll identify risk factors as well as some ways to prevent or reduce the likelihood of colorectal cancer.

We'll hear from a pair of survivors and we'll also learn about the latest treatment options for the serious but treatable form of cancer.

And we'll do all of that with the help of our panel of experts.

Dr.

Christopher Buzas is director of colorectal surgery at Geisinger, where he specializes in treating patients with colon, rectal, and anal cancers, as well as inflammatory bowel disease, including Crohn's disease and ulcerative colitis.

Dr.

Aman Ali is a gastroenterologist with Digestive Care Associates in Edwardsville, PA.

He completed fellowships in gastroenterology and endoscopy at Harvard Medical School, Mass General Hospital, and Brigham and Women's Hospital in Boston.

Dr.

Amber Sobuto is a hematologist, oncologist, and internist at Hematology and Oncology Associates in Dunmore.

She trained at Philadelphia College of Osteopathic Medicine, as well as at Lankenau Medical Center in Wynnewood, PA.

Dr.

Jason Woloski specializes in family medicine at Geisinger.

He trained at Drexel University in Philadelphia and serves as assistant program director for the Geisinger Kistler Family Medicine Residency Program.

Also joining us is Dr.

Megan Haggerty, a radiation oncologist and a partner in Radiation Medicine Associates of Scranton.

She is an assistant professor of medicine at Geisinger Commonwealth School of Medicine, and we will be talking with her a bit later in the program.

Welcome and thanks to you all.

Wanna jump right in with this important conversation.

And Dr.

Ali, I'll begin with you.

Can you define for us first, what is colorectal cancer and how does it develop in the body?

- Thank you for this opportunity.

So colorectal cancer, as you mentioned is a leading cause of cancer related death, but essentially it is just a cancer cell that is developing in the lining of the colon.

And as opposed to some of the other cancers where, you know, a spontaneous mutation and a quick pathway to the cancer development happens.

In colorectal cancer specifically, you have something what we call adenoma to carcinoma sequence, where adenomas are these polyps which are formed before the actual cancer develops.

So you have a lot of lead time, and this is one cancer where sort of God gives you a lot of opportunities to intervene along the way.

So on average, from anywhere to polyp to grow to all the way to the cancer, there's eight to 10 years timeframe.

So these polyps they develop in genetically predisposed patients as well as in the patients who have otherwise no significant family risk factors, and they slowly grow over time.

- Can you describe what a polyp is?

- Polyp are these tiny little mushroom-like or cauliflower-like growths in the lining of the colon.

And colon is a large intestine which basically is about a six to seven feet organ a long convoluted sort of an organ, which is essentially basically to store feces, but also to help with the absorption of water and has many other, you know, physiological functions.

But what happens is in the lining of the colon, these cells, when they develop mutations, they turn into these tiny little growths, which are just similar to when a dermatologist will snip off a little piece of a mole.

So these moles are in the colon, so to speak.

They will have no consequences in patient's health.

They are benign, they have potential to turn into cancer down the road, but in the early stages, that's how it starts.

It's like the seed for the cancer.

- And Dr.

Buzas, there is, when we talk about colorectal cancer, we're talking about more than one type of cancer.

Can you sort of parse that out for us?

- Well, colorectal cancer, as Dr.

Ali mentioned, it all comes from the same area, from the lining of the wall of the colon.

So there is, the colon is part of our large intestine.

The large intestine is two parts.

The first part is the colon which is the vast majority of the large intestine.

And then the last about eight inches is called the rectum, which is mostly just a storage facility for stool so that, you know, if you have to go to the bathroom, you don't have to go right now.

You can socially go at the proper time.

The treatment for colon and rectal cancer is a little bit different between colon and rectum.

Colon cancer, the treatment is mostly surgery upfront, and then depending on what we find when we do the operation, the patient may need chemotherapy afterwards.

With rectal cancer, because it's in such a tight area there's a much higher chance of us not being able to get it all upfront with doing surgery.

So many times we do chemotherapy and radiation first to kind of shrink the tumor so it's more accessible for us to get it all out when we get to the operating room.

- Dr.

Sobuto, I was reading that Northeastern Pennsylvania in general, Schuylkill County in particular has quite high rates of colorectal cancer, higher than the state average, higher than the national average.

Do we have any idea why that is?

- You know, it's something that everyone has been looking into recently, especially seeing these alarming rates in our younger patients and the patients who are younger than 50 years old.

There's a lot that's gone into the thought process.

I think there's a lot of theories, whether it's something with environment, is it diet and the way we process our foods?

But, you know, right now, we don't have a black and white answer, which I think is scary for a lot of people without knowing, you know, what exactly is causing it.

Sometimes genetics have a role but we do think that there's something more going on, you know, and like I said, either environment or diet that is largely contributing.

- Yeah, still sort of figuring that out what the ultimate reason is.

Dr.

Woloski, what are some of the most common symptoms of colorectal cancer?

What are you looking and listening for when you see your family medicine patients?

- Yeah, it's a great question.

So as a family doc, I mean, the best patients are the ones who are asymptomatic because our job is prevention and catching any potential polyp or cancer early.

So we actually want people to come to us when they don't have symptoms.

But when we talk about symptoms, especially sometimes in some of the younger individuals, it might be things like seeing a little blood in the toilet paper after you wipe yourself, having abdominal pain, maybe losing weight when you're not trying to lose weight, those kind of things.

And especially in some of the younger individuals, it seems like we always have a reason for that and we don't always think, oh, cancer.

We always think, okay, maybe it's hemorrhoids or maybe I ate something or, you know, or maybe it's irritable bowel.

And so it's really important that if you're having any symptoms that just aren't part of your normal routine, that you call your family physician so we could get you in touch with earlier screening and if God forbid something is found, treatment.

- What about the less common symptoms?

I mean, there are certain things that you might know to look for, and you mentioned a couple of them, but are there unusual ways that this kind of cancer might present itself that maybe can be a little misleading early on?

- Yeah, so I think I may have alluded to some of those and even in terms of just weight loss.

You know, someone might say, geez, I'm looking good, right?

I'm fit in this suit and, you know, but if you're not trying to lose weight, weight loss can actually be a warning sign.

So it's really important to say, am I trying to lose weight or is the weight just coming off.

You know, also even just some symptoms like feeling nauseous, you know, vomiting, feeling full and bloated.

Like those are things that, you know, there may be a hundred other reasons, but we have to think that cancer could be one of those.

- Right, and it's important too to point out, right, because we don't want to scare people that what you described are symptoms that, you know, can be very normal for people.

They, you know, every stomach ache isn't cancer necessarily, right?

But I guess when it's a repetitive kind of thing or it just seems like it's out of the norm, it's worth getting checked.

- Yeah, and it's all about having that relationship.

And, you know, in family medicine and primary care, we always say, you know, get to know your physician, you know, and if it's something that just, hey, this doesn't sound like something that you've had before, you know, we can pick up on some of those red flags as well.

- Speaking of red flags, we have a survivor with us.

Amy Carney knows a thing or two about unusual symptoms.

Amy is with us in the audience.

Amy, tell us what unusual symptom you had that you would never have associated with colorectal cancer.

- I was having trouble swallowing.

I was having a lot of pain when I swallowed any type of food and that led me to the doctor and they did blood work and my hemoglobin was 5.4.

So then I needed blood transfusion and that's how they led me to the colonoscopy and endoscopy and then found the cancer.

- Can you tell us a little bit about what your treatment was like?

- I did chemo and radiation, oral chemo and IV chemo.

Ultimately, my cancer spread, so I had to have a permanent colostomy and have everything removed.

- How did you get through that time?

I mean, you say it very matter of factly, but that had to be an incredibly stressful time in your life.

Can you tell us a little bit about kind of how you managed all of that?

- My family and friends, that's helped me through it, being positive and have everybody around me to help me support me and take me places and do anything I needed.

- Did you have any family history at all of colorectal?

- I did, but they did the testing and mine wasn't hereditary or genetic.

So it just picked me.

- How are you these days?

- I'm doing really good, back at work, doing good.

- Cancer free.

- Cancer free.

- Great.

(audience clapping) Amy, thank you.

Thank you so much for sharing that with us.

We will hear from another colorectal cancer survivor in just a few minutes.

Dr.

Buzas, colorectal cancer has also been referred to as the silent disease or a silent disease.

And to Dr.

Woloski's point, sometimes there's just no symptoms, and I guess then you would find it with a colonoscopy?

- Correct, I mean, that's how we wanna find it is when you aren't having symptoms, because once you start having symptoms, the chances of it being more of a advanced cancer is much higher.

So that's why we wanna do screening colonoscopies as opposed to waiting till you become symptomatic and us being more concerned that we're gonna find something.

So that's why we do the colonoscopies on a regular basis to make sure as Dr.

Ali said earlier, it does take a while for colon cancer to form.

So we do have time to find it before it becomes a cancer in itself.

So I think that if you go through your normal colonoscopy screening calendar, that the chances of you developing cancer are very low.

- Well, let's talk about colonoscopies for a moment and screening and what that entails because I think for people who have not had a colonoscopy, there's a lot of mystery surrounding how that works.

Dr.

Ali, I'll begin with you.

What does a colonoscopy entail?

- So colon, it's an organ where the stool is stored, so you need to clean that out so the cameras can see it in an adequate fashion.

Not only we can see what's going on in the colon, but we also like to take care of these polyps or early growths, which can turn into a problem down the road.

So for that purpose, we need to clean the colon out.

So the usual preparation is the patient will go on a liquid diet, so they're still able to drink a lot of water, you know, electrolyte solutions, clear broth, anything which is clear liquids which is not going to interfere with the visualization of camera, they could have that the day before.

And usually you know, family practice or the primary care docs, they will send us the patients.

They will already make sure that they have adequate cardiovascular and other anesthesia clearances to be able to undergo sedation.

And sedation is a minor sedation.

You do this test usually in a outpatient setting in a surgery center even.

You don't have to necessarily go to the hospital.

It's a very minor procedure.

And so sedation is not general anesthetic.

There's no significant risks associated with that.

But having that day before colonoscopy, which is probably the most feared day, you basically are on liquid diet and then a laxative, a purgative is given in a medicinal form, which I must mention are much improved now.

So they are not what they used to be and much more user-friendly than they were before.

So yes, a little cleansing of the colon is needed.

Now, I mentioned that there's a lot of you know, in Hollywood and everywhere else, these movie stars, they're doing the colon cleanse and all of that.

This is easier than that.

You know, if somebody ever had a colon cleanse, they will tell you they're awake during that.

They're inserting a tube and inflating it with water and it's uncomfortable.

A lot of cramping is happening.

None of this is happening with colonoscopy prep.

So you drink that liquid, you essentially are cleaned out, you show up for the surgery center or the place where you can have a scope.

You'll get a small little IV for sedation purposes.

And I'm telling you my own experience because I went through this and then the next thing you know, you're waking up in recovery asking if it's over because the colonoscopy is the easiest part as a patient.

About 15 to 20 minutes procedure, you're sleeping through it, some of the best sleep you get in your life and it's over.

- And it's a small investment to make, you know, to potentially discover that there's something there that needs to be taken care of.

Suppose that, you know, you do a colonoscopy there's not cancer necessarily present, but you see something that might be problematic, what then?

- So there's various grades of what could be the precancerous growths there.

So they're your ordinary small polyps that as we're going along with the camera, we're watching them.

As we see them, we just basically remove the polyp and we suction that polyp out and send it off for biopsy.

Every single polyp we remove, we test it.

And that's how from pathology, a few days later, we find out what grade and what kind of polyp that was.

Sometime we find the growths which are much more involved and they require specialty procedures which may require another colonoscopy, not necessarily a surgery, but a more refined procedure such as endoscopic mucosal resection or endoscopic submucosal dissection.

In simple words we need more delicate instruments and micro dissection and microsurgery to take still that very early polyp, which is right at the verge of developing cancer.

I tell you, nothing makes my day other than just saving somebody from that sort of destined outcome otherwise.

So there's a huge amount of techniques in the recent 10 to 15 years available, including some techniques which, simple words I can define as like laser treatment during endoscopy you know, cauterizing it, cutting it, so forth, everything to try to prevent patient from undergoing surgery and, or chemotherapy.

- Dr.

Buzas, at what point should people start having colonoscopies, what age?

- Well, if you have no risk factors or any family history of colon cancer, then we suggest that you start getting colonoscopies at the age of 45.

Now, depending if you have risk factors, meaning other family members in the past that have had colon cancer or family members that have had multiple polyps in the past or other risk factors, then we may ask you to get started earlier, even up to 10 years earlier than 45.

But if you have no risk factors, 45 is the standard time that we usually ask people to start.

- Well, and speaking of getting started, Dr.

Sobuto, I mentioned that while rates seem to be slowing somewhat in the older population, and we tend to associate colorectal cancer with an older population, younger people have been getting diagnosed with this over the last, I don't know, 10, 15 years.

By younger, I mean, under 50.

Do we have any way to account for why that's happening?

- You know, I think it goes back into those, is it environmental, you know, is there something genetic?

Is there something in our diet?

But I think, again, the biggest take home point is that any symptoms you should get screened, you know, and you should bring it up to your primary care physician so they can investigate it further.

I see a lot of patients, you know, for anemia and their big explanation is, oh, I've been anemic my whole life, but we really have to make sure, do we really know why you're anemic?

Do we really have a clear cut reason?

And if things aren't getting better, it does take, you know, the time and investigation to make sure that we're not missing anything.

And I think that's frequently what I see in terms of the younger patients presenting is that they are anemic and they might not recognize that there is blood in the stool.

I think that's a big misconception.

They say, well, no, my stools are the normal color, but you could have, you know, microscopic bleeding that their stools could look normal.

And they might not realize that over time they've been oozing from either a polyp or a colon cancer and it's just gone missed or they just chalk it up to the anemia that they've had for a while.

- Yeah, and this is the argument, Dr.

Buzas, for potentially starting earlier, right?

I mean, family history, those kinds of things.

And speaking of younger people being diagnosed with colorectal cancer, I mentioned that we have another cancer survivor with us.

Ginger Walsh is joining us.

And Ginger, thank you for being with us.

Tell us how old you were when you were diagnosed.

- I was 44 when I was diagnosed.

It was a little bit actually after my 44th birthday.

So it was, my birthday was in October.

I was diagnosed November 11th of 2019.

- And like Amy, you had unusual symptoms.

- Yes, like Amy, I did, I had unusual symptoms.

I really didn't have any symptoms until all of a sudden I did.

I know someone in the panel said that throwing up can be a symptom.

I was sporadically throwing up.

I just, I drove my daughter one day to Philadelphia to drop her off on the way home.

We were carpooling, I was in the back of the car.

I got sick all of a sudden and I was just throwing up.

I thought that I had food poisoning, it ended there.

The next week, I went to Luzerne County Fair, again, dropped my kids off, came back, and I was throwing up.

There was no rhyme or reason to it.

I could be standing like I am now, talking to you, and then all of a sudden I would be violently throwing up, and it just kept progressing and progressing.

I didn't have, I mean, I wasn't feeling the greatest, but I didn't have any typical symptoms that you would think, nothing that was really alarming to me that I thought, okay, I could maybe have cancer, nothing like that.

And what I learned is that it probably started about 10 years ago, but at the time I was 44, you know, I didn't know that I should be getting it.

It just wasn't on my radar, which is one of the reasons why I'm here and speaking because it needs to be on people's radars, for sure.

Even if you're not having symptoms, I mean, you could have something there and it's very preventable and you just need to listen to my story, to Amy's story.

I have pictures here of people who have passed all in Wilkes-Barre or GAR or Luzerne County, 50 or younger, and they passed away, but you can prevent it.

And that's what I want people to know, you can prevent it.

- Yeah, and you mentioned that you had five friends who had passed away all young from colorectal cancer.

I'm curious too, how did you ultimately connect the dots from the symptoms that you were having to discover that it was colorectal cancer?

- So I went through a lot of different testing.

Eventually what happened is I got an ultrasound and they found a lesion on my liver, still not thinking that it was colorectal cancer.

And then finally, I had a liver biopsy after all of the other tests were done, and then I got the call that it was colon cancer that had spread to my liver.

But it was I would say about, just about a month it took for the diagnosis to come through.

- And what was your treatment like?

- I went to Sloan Kettering.

I had systemic chemo, and then I also had a hepatic arterial infusion pump that gave me chemo directly to my liver at about, I wanna say like 200, 300 times the amount and that was to prevent the liver cancer from coming back.

So that ended in about 2020, and since then, thank God, I have been cancer free, sorry, nervous.

(audience clapping) - Ginger, thank you so much for sharing your story.

We are delighted that you and Amy are here and with us, and it speaks to medical science and the amazing things that can be done, Dr.

Ali.

- So, I'm really moved by these stories, but I do see them in real time also on day to day.

This week alone I have a gentleman who's only 33 year old and he has a rectosigmoid cancer and didn't think much of it other than just some diarrhea, some constipation alternating.

Again, going back to the point not being himself, sometime it could be just simple fatigue and just, you know, you're just not yourself, changing bowel habits.

It could be just diarrhea and some patient constipation of the patients.

Anyway, he just showed up because his girlfriend insisted that he should be checked.

And thinking that his father had Crohn's disease, he thought maybe that's all it is.

And here I am diagnosing him with stage four colon cancer, very hard to say to a 33 year old, otherwise full of life, looking completely normal and healthy person.

I had healthcare providers who work at Wilkesburg General Hospital who were themselves RNs at the forefront, taking care of patients.

And they had these minor bleeding episodes and they thought they were hemorrhoids.

Sometime they waited five, six, seven months before they actually finally seek my advice and we diagnosed them and got them cured long term.

I was here in the panel eight, nine years ago, and at that time, we had a 28 year old who had beaten the cancer, stage four and her daughter was only about three or four at the time and she's still okay.

She's still my patient.

I still do her follow-up colonoscopy.

So I think the point is, it's not all doom and gloom and there is hope, but I love to be, and we all love to be the colon cancer preventers, not detectors.

- Yeah, well, Dr.

Woloski, speak to that person who may be listening to our conversation and feeling anxious because we've talked about all kinds of symptoms that you wouldn't necessarily associate with colon cancer, but speak to that person who is hesitant, who is anxious.

And again, you know, we wanna emphasize that every symptom isn't cancer, but we also wanna balance that with the necessity of screening.

So how do you talk to your patients about this?

- Yeah, so it's a great question.

And I think it's multifaceted, right?

So it also goes along, do I find anything on exam?

Are you seeing any red flags in blood work?

So, you know, I always say, just don't Google everything because you're gonna, you know, come and always say, you know, everything's doom and gloom, but I think that's the benefit of having a healthcare team where you could find some of those pieces.

If you're not anemic and X, Y, Z looks good and all this else looks good, well, you know, maybe there is, you know, a more benign understanding, but just very quickly, I also wanted to mention that we've talked a lot on the panel about colonoscopies, but, you know, there is other technology available for screening.

And I think it's very important for individuals who are asymptomatic, so you're not having symptoms, you have no strong family history.

And for the most part, you know, to your knowledge, no first degree relatives or anything that would preclude you from doing one of these other tests, there's home tests out there now.

And so much so that we've made it so easy that, you know, I call it my goody bag that if you fit these criteria, I could send you home with your goody bag and you could do this home test.

And often, and like I said, it's for a select few.

It doesn't mean everyone can do that test.

But in those individuals, it might be really something they didn't even think existed, and it goes far beyond just looking for blood.

We're actually more sophisticated.

We're actually looking at DNA of abnormal cells.

There's also some upcoming research on blood tests for colon cancer.

I think, you know, the verdict's still out on how great that is.

But, you know, if you have someone who absolutely will not do a colonoscopy, absolutely won't do a home test, and you think, well, geez, maybe something is better than nothing, you know, I think this is where you're having discussions with your healthcare team is very important.

- Absolutely, and I think, you know, I was reading about the blood test as well.

I mean, certainly sounds a lot easier than a colonoscopy.

But, and if you are low risk, that's great, but if you are at a certain age, if you have family history, then it sounds like the colonoscopy is the way to go.

- Yeah, absolutely, and it will always be the gold standard.

- I think it's important to find out though, like the Cologuard we're talking about.

Yes, I think I agree with the fact that the best screening test is the one that actually gets done.

Having said that, you have to really know what you're getting into.

I mean Cologuard and the genetic DNA based testing or the fecal testing, they are fine, but you have to really know that how much you're missing.

So even with Cologuard, the advanced adenoma detection rate is only about 40%.

So meaning six out of 10 people are gonna walk around with a happy face that they have a negative test, and yet they have something, a ticking time bomb in their colon that they don't know about.

So colonoscopy remains the gold standard.

Back in 90s, the mortality rate from colon cancer was almost double what it is now due to the colonoscopy.

So colonoscopy is making a huge difference.

These old tests, if somebody really doesn't wanna do, that's fine, but by no means I would say they are replacement for colonoscopy.

- And if they're positive, then you get a colonoscopy.

- Well, that's an important point because a lot of people, when they have their insurance allows them a screening test, that screening test is whatever you choose.

If you choose Cologuard, that is your screening.

Now when you go for colonoscopy, all the deductibles and insurance copays, all those things will apply.

So a lot of people are extremely upset and disappointed in finding that, that they use their free card for colonoscopy in something which they shouldn't have used.

- And also the Cologuard has a very high false positive rate.

- 73%.

- And so even if you may not have an advanced polyp or colon cancer, sometimes the test comes back positive.

And then that gives a lot of fear to patients.

And God forbid, we go in and do a colonoscopy and we don't find anything.

It doesn't give the relief that just doing a colonoscopy would in the first place.

- Creates an awful lot of unnecessary anxiety.

It's not full proof.

- And you don't know where these cells came from.

I mean, is it from the stomach, is it from pancreas?

So then you go on this wild goose chase and there is no end to it.

So I think doing the right thing is not easy, but it's the right thing.

- Dr.

Sobuto, what are some of the things that we can be doing to prevent or at least lessen the risk of colorectal cancer, of cancer generally for that matter, but in this case we're talking about colorectal.

Like what are some things that we have control over that we can do to increase the odds of a good outcome?

- Yeah, so, I mean, I think it's really important that we talk about maintaining a healthy diet.

Obesity is a risk factor for colorectal cancer, smoking, alcohol.

Those are all things that you can control, you know, and you can have some say in terms of decreasing your risk for developing a cancer.

So it's just important that, again, these are conversations that it's not easy.

You know, none of these things are easy, but having that conversation with your primary to see like, how can I optimize my health and what changes can I be making on a daily basis that helps me moving forward and decreases my chance of having to need anyone on this panel.

- And Dr.

Ali, are there certain groups that are maybe more predisposed to colorectal cancer?

- So I think family history and those genetic syndromes, which are thankfully rare, less than 5%.

But generally speaking the risk factor when I look at it is obesity, sedentary lifestyle, you know, high amount of alcohol intake.

All these process means that you know have a lot of nitrosamines, which are also risk factor for gastric cancer.

And a lot of our process, red meats and stuff.

Vitamin D deficiency is also linked as one of the main risk factors for colon cancer.

So yes, but having said that, if you have a first degree relative or two second degree relatives, then that is considered a risk factor.

And then whenever the first index cancer in their family was diagnosed, let's say somebody has a cancer diagnosis at 42, so the first degree relative should have colonoscopy at 32.

10 years prior.

- I wanna dive a little bit deeper into treatment.

And Dr.

Sobuto, I wanna talk about chemotherapy, both of the survivors that we talked with have experienced that.

What does chemotherapy look like in the case of colorectal cancer?

- So it really depends, you know, first the question is, are we dealing with colon cancer or are we dealing with rectal cancer?

'Cause we really change our therapies based on that.

As he mentioned, you know, if we're dealing with more of a rectal cancer and how difficult that surgery is, we have pushed a lot of that treatment to upfront.

You know, we've found that treating patients with chemotherapy and radiation therapy, followed by chemotherapy can really help shrink our tumors and decrease what they need to do at the time of surgery if they need surgery at all.

I would say the chemotherapy in the colorectal cancer in this field is relatively well tolerated.

You know, you're talking about medications that people typically can work through.

Of course, there are side effects to these medications, but we have wonderful therapies now to help treat and prevent those.

You know, our medications that have come out for treating nausea and vomiting, all of the things that people fear have really advanced over the past few years.

Where we're talking about these medications, some of them, like she said, are pills, you know, and you get a low dose when you're getting the radiation therapy, people tolerate it very well, and they do very well, they respond very well.

But really what has changed in the past few years and what is upcoming in the future of this is we're really getting into why the cancer happened from a molecular level.

We're able to find out, you know, what is the driving mutation?

What took this cell from being a normal cell into a cancer cell?

And can we target that?

You know, are there any specific therapies that go after that mutation and can really treat it without causing as many side effects, you know, or just being your standard chemotherapy?

Immunotherapy has also come into the field the last few years.

I think everyone has heard of these medications and they're really allowing your immune system to fight off the cancer.

So a lot of times we're using them as a combination approach.

Your chemotherapies go after the cancer cells.

They really target the cancer cells that are growing quickly.

And then by giving the immunotherapy, it allows your immune system to go after and fight the cancer.

So they work very well together.

Again, like I think they're much better tolerated today, but the best thing is to not need me or chemotherapy.

So again, getting the screening earlier, you know, the earlier stage you catch the cancer, the less likely it is for you to need things like chemotherapy or immunotherapy.

- We're very fortunate to have a radiation oncologist with us, Dr.

Megan Haggerty.

I mentioned her earlier in the program.

She is an assistant professor of medicine at Geisinger Commonwealth School of Medicine.

And Dr.

Haggerty, tell us about what radiation might entail for someone, and we talked about this a little bit earlier, that it depends on the type of cancer you have, first of all.

What kind of cancer requires radiation, and then what does that look like?

- So colon cancer generally is not treated with radiation.

That's more of a surgical type of treatment and chemotherapy.

But once you get lower in the GI tract into the rectum, the rectum sits in a very tight place in your body, in the pelvis.

And so the adjacent organs and the surgery, it's more difficult.

And it's also, you know, that part of the body, we want to be able to reconnect the colon to the anus.

And so it just, you know, the surgeon really does not have a lot of tissue to work with.

And so with the use of radiation treatment and with chemotherapy, oftentimes given together for patients with rectal tumors, we can shrink the tumor and allow for the surgeon to then come in and more easily, effectively remove the tumor while hopefully being able to preserve the patient's anatomy.

So, you know, I think that a lot has changed in the treatment of rectal cancer.

I think it's actually improved quite a bit the past 10 years.

We're getting good at treating it, and so that's allowing us to be able to actually concern ourselves with patient's quality of life, because we want them to be cancer free, and we want them to be able to live well.

And so I think that over the past 10 years, with a lot of some changes in the way that we treat patients, we try to use chemotherapy and radiation therapy to shrink the tumor down and allow for as small of a surgery or occasionally no surgery to allow to preserve a patient's quality of life.

- Well, and speaking of quality of life in your experience working with the patients that you've worked with, how do these therapies affect quality of life, at least during the time that the treatment is ongoing?

I mean, what can people expect?

- Well, I think that there's so much that comes with the cancer diagnosis that, you know, it's like sometimes you can't work and so you can't make money.

And so, you know, that, and then you're scared you're gonna die and, you know, these, you know, patients would know it best.

But then on top of it, you're like, have real side effects to treatment.

I think things have definitely improved for many patients.

You know, as far as with radiation goes, we are allowed to really use smaller treatment volumes to try to minimize the radiation that goes to organs adjacent to the rectum.

Chemotherapy in many ways is better tolerated you know, and so I think that it is definitely hard.

I think hopefully for many patients, it's getting better.

But yeah, I think it's a real challenge.

- Yeah, and finally, can you speak a bit to how you as a medical professional and you're dealing with people who are undergoing radiation how you help them sort of handle the mental, emotional aspects?

I mean, they're devoting so much attention to their physical self but there's so much going on, to your point, mentally and emotionally.

And I guess my question is, how can healthcare providers sort of help a patient manage the mental and emotional side effects of treatment?

- I think that you just have to give a lot of yourself to your patients.

Like I see my patients weekly during treatment.

So I get to check in with them all the time.

I think surrounding yourself with people who do the same, like in your office.

Like our therapists take our patients back to the treatment room each day and they know if something's not right or the patient, you know, something's up with a patient.

So I think just patients rely on us.

You know, so I think we just have to show up for them and provide, you know, a place where they can call if like something's not right.

I'll talk to them.

I always tell them, you ask for me.

- Well, thank you, Dr.

Haggerty.

And Dr.

Sobuto, to Dr.

Haggerty's point, I mean, you also are working with people who are undergoing chemo and, you know, there's so much anxiety just around this whole process.

People are anxious about getting a colonoscopy and doing the preventative things.

And then, you know, if there is a diagnosis and then you've got to undergo treatment and, you know, you hear chemo and that's scary.

So from your perspective, and pretty much the same question that I asked Dr.

Haggerty about just being able to guide a patient and help them navigate the mental and emotional aspects of treatment.

- Yeah, and I think it's such a huge challenge for them because it's a rollercoaster.

You know, they're starting off with their screening and hearing this diagnosis and then we're throwing all these abbreviations and words at them and sometimes I tell them, listen, it's okay to not be okay.

It's okay to tell me you're struggling, and having that ability to say, listen, this is a hard week, maybe not physically, but maybe emotionally.

And reaching out to us, no matter what it is, if it's stress, if it's anxiety, if it's symptoms, they know that they can call our office.

You know, we have counselors in the office who are there to talk to our patients.

We have, you know, sometimes the primaries know them or have known them for so long that they really can help us and help support them through this.

But I think, like she said, it's just showing up for them and telling them like, it's okay to not be okay and to lean on us if you need us for anything.

And they don't just get to know us, they get to know our nurses, they get to know our staff.

And I think that community setting, that feeling that they're seen and they're known and that they're cared for by everybody in our office.

Like our chemo nurses know our patients so well.

Like they're so invested in their life and they're having these conversations with them, helping them get through the treatment.

So just knowing that we're there for them throughout everything.

- Dr.

Buzas, I wanna talk a little bit about surgery and what that can look like.

You know, we hear about robotic surgery and minimally invasive surgery.

Can you give us a sense of kind of what the surgical picture might look like for a patient with colon cancer or rectal cancer?

- Sure, it all depends on the stage of the cancer, so how involved it is.

With a very early stage colon cancer, it can even be treated without surgery.

Somebody like Dr.

Ali can take them out without needing what we call an advanced surgery or a large surgery.

So if you get diagnosed with a very early stage cancer, it can be treated through a scope instead of a knife.

Once you get into the more intermediate to late stage cancers, the idea of the surgery is to take all of the cancer out.

And so we do have minimally invasive techniques of doing that.

The idea is that if we make smaller incisions, then the chances of a complication are less and the chances of, and the recovery is much faster.

The other idea is that, you know, we do wanna make sure that people have the best quality of life and we wanna try to keep them without needing a colostomy.

Unfortunately, one of our survivors does have that, but over the years, we've gotten much better in our surgical technique to be able to put people back together so that they don't have a permanent colostomy.

And then the other thing is quality of life.

So specifically in rectal cancer you know, one of the, you know, as I said, the job of the rectum is to make it easier for you to go to the bathroom.

So if we take that out, then one of the downsides of that is you'll never have normal bowel movements again, and the idea with surgery is we wanna leave as much as possible so that your quality of life can be as good as possible.

- And you mentioned the colostomy bag and, you know, people hear about that, may not understand exactly what that is and there is anxiety about the prospect of that.

Can you explain what that is?

- So what a colostomy bag is if for some reason we cannot put the bowel back together after we do surgery, whether it be because of risks of putting people back or if technically we just can't put the bowel back together then we have to take whatever the end of the gastrointestinal tract is in the patient, we have to bring that out through their abdominal wall.

So no longer will they be passing their stool through the anus, they would be passing it through a loop of intestine that comes out through the abdominal wall and then empties into a bag.

And then the bag the patient learns how to empty it and then the bag usually has to be changed about every three to five days.

- Dr.

Ali, we talked with two survivors who have been cancer free for a while now.

Is it your experience that most people who are treated successfully for colorectal cancer can then go on and live a pretty normal life?

- Yeah, it is one of the successful stories you know, again, timing is everything.

So all of my colleagues who are highly talented and expert in their fields, we're hoping to prevent the cancer to get to the point or develop to the point where the surgery is needed or chemo or radiation is needed.

So I have countless patients where they had what we call intramucosal carcinoma or the very, very early stage as we were discussing earlier, that cancer and we basically remove it with a scope and they go home and having normal dinner with their family the same night, no chemo, no radiation, no surgery, no colostomy bag.

They think it was just a screening colonoscopy, but we literally save them from all that heartache down the road.

So some people don't quite realize how impactful timing and early detection is.

So as I said earlier, prevention is one thing, but you know, detecting it is one thing, but prevention is, I think is far better to catch it early.

But the people who did have the colon cancer and it was successfully treated with all the modalities we've discussed, they live relatively normal with some change in their bowel habits, obviously, you know, because portion of the colon's missing, pretty fruitful and full life.

And I did want to also expand on what you say that none of this is possible without our excellent team that we work with.

These nurses were bringing the patients from the front from the waiting room all the way to the sedation to getting the procedures done.

Shout out to my own team who's present here.

I really appreciate them being there.

They really are, you know, from like Gateway Surgery Center, they're excellent nurses who are available who literally save lives on a day to day basis.

But again, you know, it's one of those things that you prevent something, it doesn't seem like it has that much impact, but it really does because this is one of the cancers as opposed to brain cancer or some of the other cancer where you don't have screen, or pancreatic cancer, for example.

You don't have the screening tests available.

And here you have after a number, number, years after years, you have opportunity to make a difference and avoid this.

- Dr.

Sobuto to that idea about a team, patients do typically have a team that works with them.

Can you, and I know that while you all represent different aspects of treating colorectal cancer and discovering it, can you talk about that, the nature of that teamwork and kind of who's on the team and how do you all work together to bring about the best possible outcome for your patients?

- So usually, you know, obviously it's starting a lot of the time with our primaries who set up the screening and get the patients in to CGI, but I think we're working in a place like Northeast PA, it's wonderful because we know each other.

You know, it's so easy to pick up the phone and say, listen, I'm worried about this patient.

I need to get them in.

Or, you know, this is happening on treatment.

I'm worried they're not responding like they are.

Can they get to surgery sooner?

And we have wonderful physicians and sometimes it requires us to reach outside the area.

You know, we work with tertiary centers all the time when maybe things are not going as we want them to, or maybe something is unique and different.

And I just think it's so important that you have that communication and that you're able to speak to the other providers.

So we're getting, you know, the best plan for the patient and that specific patient.

You know, we used to see patients who had metastatic disease, you know, we were treating them without doing aggressive surgery or without doing aggressive interventions, but now that tide has changed as well.

You know, as our survivor mentioned, she had disease in the liver and we used to just say, okay, listen, it's chemotherapy until it stops working, but now we found that, you know, with our advanced surgeries and with these liver directed therapies, we're curing patients who wouldn't be cured before or we're at the very least, you know, expanding their life for years, you know?

So it's just really important that you have that communication, have that open communication, and you're doing absolutely everything that you can for the patient in front of you.

- And Dr.

Buzas, to that point, I think it's important to just spend a little bit more time talking about maybe what's in the pipeline.

We've touched a little bit on, you know, some newer therapies, but where do you see all this heading in terms of treatments that will be available to patients?

I mean, do you have a sense of what's on the horizon going forward?

- Certainly there is always new and interesting studies being done on new medications, immunologics for chemotherapy and newer radiation treatments for, you know, mostly for rectal cancer.

But one of the things that we have noticed is that, especially in rectal cancer, knowing it is a very complex treatment algorithm, many patients don't get the standard of care treatment and there is accreditations, there's nationally accredited centers in our area for rectal cancer where we have a whole team that comes together, it's medical oncologists, radiation oncologists, surgeons, pathologists, radiologists, and we go over these specific cases that are more complex and if you can have the whole team in the same room or at least in the same meeting, then you can get a, you can come up with an organized treatment plan so that when all of the doctors are talking with the patients, you're all on the same page.

So I think that that's one of the things that's in the future is that we need to have more centers doing this, what we call multidisciplinary care to make sure that the patients are all on the same page with all of the doctors and that we're doing the things that are the gold standard for treatment.

- And I would imagine that in those groups, you know, you just have the benefit of brain power, right?

Of having other colleagues who may have seen an unusual thing that you have not yet seen or maybe treated someone in a way that you have not done before so that you can sort of, I guess, trade best practices really.

- Well, it's that as well as every patient is individual and everybody, it's not a cookie cutter treatment.

So if you're all on the same page at the same time, then you can look at the other aspects of the patient, you know, psychosocial issues, other medical issues that the patient might have so that you can really hone a very good plan for the patient to have the best chance of a good outcome.

- I wanna ask each of you, and I actually would like to go back to Dr.

Megan Haggerty.

I wanna begin with her.

And I'd like for each of you to just give us a final thought you know, maybe the best argument that you have for doing screening and prevention, because that has been a recurring theme throughout this conversation, but I wanna begin, Dr.

Haggerty, with you.

Final thoughts, what do you want our listeners and viewers to take away from this conversation?

- Well, I'll just repeat, you know, something that's been said several times, but colonoscopy, it actually prevents cancer.

You know, like I take care of a lot of patients with breast cancer and they have their mammograms every year, they can't believe they got breast cancer, but mammograms don't prevent breast cancer, but colonoscopies actually can prevent a colon cancer.

So I think it's a very, very powerful tool.

This is, you know, this is, like, this is the poster child for a preventable disease.

And so I think you have to just take it upon yourself to get yours scheduled.

- All right, thank you, Dr.

Haggerty.

Dr.

Woloski, you are our primary care physician.

What do you say?

- Yeah, so I would say, you know, I know there's definitely listeners and people watching who probably have not seen their family physician in quite some time.

So I would say give us a call.

Because, you know, it's these discussions, most people may not realize, hey, I'm 45, I feel great, but gosh, I didn't know.

I should be screening for colon cancer.

So really you know, if you see the dentist twice a year, seeing me once a year isn't that bad.

- And you're often the first line of defense.

- There you go, yes.

- Dr.

Sobuto.

- You know, I think it's just important to realize that cancer care has really changed drastically in the last few years, and it's really important, yes, preventive, but also don't shy away from this just because you're scared of the one story you heard 10 years ago about how someone did, you know, because their experience is not your experience.

And of course we want to prevent it, but if you do have a cancer diagnosis, we have, you know, wonderful new technology, new chemos, new surgery, you know, that we're gonna be here for you and treat you the best we can.

And, you know, there's so much coming in the cancer world.

- Dr.

Ali.

- Yeah, just to reiterate the point, as my colleagues mentioned that the technology has advanced.

When I was in fellowship about 15, 20 years ago there were treatments that were just, we did not think they were possible.

And endoscopically speaking, ultra minimally invasive, patients can have the cancer prevented and detected way more earlier toward the left of the shift.

So I would say you know, just have that awareness and have a community programs like this.

This is extremely important.

I would like to mention there's another program in Scranton.

I think it's a rock concert by a gastroenterologist actually on 27th of this month.

They're raising awareness through music.

So the community programs like this is very important.

And I think just talking to someone who went through the experience of colonoscopy and hopefully they will tell the true, the exact way that they went through and it's not as bad and how it can help the patients, I think it really will be the way to go.

- Yeah, trusted voices.

Dr.

Buzas, what do you say?

- What I would say is, God forbid you do get diagnosed with colon cancer.

I went into this field because colon cancer is one of the most curable types of cancer we have.

So if you get diagnosed, you're gonna have to, unfortunately, it's gonna be hard to get the initial diagnosis, but there are many, many treatment options, so just have a positive attitude when you get into that.

- I think that is the perfect note to wrap up our discussion, and that is about all the time we have.

Many, many thanks to our panel for helping all of us to better understand the risks, the prevention strategies, and the treatment options for colorectal cancer.

We are also deeply grateful to Amy Carney and Ginger Walsh for sharing their courageous stories with us.

For all of us at WVIA, I'm Tracey Matisak.

Thanks so much for joining us for "Conversations for the Common Good".

(audience clapping) (calm music) - [Announcer] "Conversations for the Common Good" was underwritten by Geisinger College of Health Sciences, research and education for a new generation of learners.