Colorectal Cancer Program
INCIDENCE AND PREVALENCE
As stated by the American Cancer Society, colorectal cancer is the third
leading cause of cancer-related deaths among men and women in the United
States, and while survival rates have improved over the years due to increased
screening, the disease is on the rise in young people.
PROGRAM OVERVIEW
Hoag’s Colorectal Cancer Program brings together a multidisciplinary
physician team to collectively evaluate and treat patients with cancers
of the colon and rectum.
The program at Hoag provides highly personalized and evidence-based care
to more patients than any provider in Orange County and achieves outcomes
consistently above national figures.
Babak (Bobby) Rad, M.D., is the program advisor for Hoag’s Colorectal
Cancer Program. Dr. Rad is fellowshiptrained in colon and rectal surgery
and has dual board certifications in general and colorectal surgery. He
coordinates the multidisciplinary colorectal cancer team
comprised of colorectal surgeons, medical oncologists, radiation oncologists,
advanced endoscopists, pathologists, radiologists, and gastroenterologists
who discuss patient cases during the biweekly GI Tumor Board.
DIAGNOSTICS
Screening colonoscopy remains the most effective method for early detection
of colorectal cancer. Hoag Endoscopy Center’s Adenoma Detection
Rate is consistently above national averages. (See Figure 7)
Imaging modalities available through Hoag Radiology expand and enhance
diagnostic capabilities for colorectal cancer patients at Hoag. These
include high resolution CT scans and PET scans for both the initial staging
of colorectal cancer and for subsequent surveillance to exclude recurrent
disease after surgery. High soft-tissue contrast imaging of 3T MRI scan
is performed to accurately stage rectal cancer. MRI allows for assessment
of extramural tumor spread and involvement of the sphincter complex and
mesorectal fascia. Furthermore, for patients who may not be candidates
for colonoscopy due to an elongated colon, anatomical restrictions, or
an inability to stop the use of blood thinners, Hoag offers CT colonography
(virtual colonoscopy).
Hoag’s interventional gastroenterologists are specially trained and
highly skilled in the use of endoscopic ultrasound (EUS) for rectal cancer
staging and the removal of large precancerous polyps and early cancers.
TREATMENT
Tumor Board
Colorectal cancer cases are discussed at the multidisciplinary GI Tumor
Board attended by surgeons, GI medical oncologists, gastroenterologists,
advanced endoscopists, radiation oncologists, pathologists, radiologists,
palliative care specialists, and the GI cancer nurse navigator.
GI Tumor Board is held on the 2nd and 4th Monday of every month at 12:30 p.m. at the Patty & George Hoag Cancer
Center in Newport Beach and via videoconferencing at Hoag Cancer Center
Irvine. It is moderated by John Lipham, M.D., James & Pamela Muzzy
Endowed Chair in GI Cancer. To submit a colorectal cancer case for the
GI Tumor Board, contact the GI Cancer Nurse Navigator, Diane Eadie, R.N.,
at 949-764-8267 or [email protected] or Rosana Figueroa at 949-764-7044
or [email protected]
Surgery
Hoag’s colorectal cancer surgeons are board-certified and limit their
practice to colorectal surgery, maintaining specialized focus and expertise.
They are skilled in roboticassisted surgery and sphincter-sparing procedures
for patients with rectal cancer.
Implementation of the Enhanced Recovery After Surgery protocol for colorectal
patients occurred in 2017. The combined effort among surgeons, anesthesiologists, and nurses has
significantly enhanced the patient experience by decreasing length of
stay, promoting earlier ambulation and food consumption, and minimizing
the use of narcotics in pain management. The colorectal surgeons incorporate
information about the ERAS protocol into their pre-operative education
with patients.
Medical Oncology
Hoag collaborates with fellowship-trained medical oncologists who subspecialize
in GI cancers, adding expertise and knowledge of the latest research and
novel systemic therapies to the colorectal program.
Patients who have advanced disease receive comprehensive molecular profiling
at the beginning of care as well as periodically throughout their treatment
with liquid biopsies to understand changes in their tumor’s biologic
behavior. Periodic testing allows medical oncologists to determine if
there are new resistance mechanisms building or new targets for treatment.
Those potentially targetable genetic mutations or alterations are aligned
to therapies that may be off label or available through a clinical trial.
Through Hoag Family Cancer Institute’s Developmental Therapeutics
Program in alliance with USC Norris Comprehensive Cancer Center, colorectal
cancer patients have access to some of the newest agents available through
phase I and II clinical trials. This not only expands treatment options
for patients with advanced disease, in some cases, early phase clinical
trials may be part of first or second line therapy.
Radiation Oncology
The program utilizes pre-operative radiation therapy and chemotherapy to
aid in the downstaging of rectal cancers to a more definitive resection.
Hoag’s Radiation Oncology Department provides image guided radiation
therapy and 3D conformal radiation therapy (3DCRT) using state-of-the-art
linear accelerators: TomoTherapy®, Elekta Versa HD™, and Elekta
Agility™.
TomoTherapy uses hundreds of pencil beams of radiation, rotating in a spiral
around the tumor and hitting it with varying intensity from all directions,
providing incredible precision. Daily CT imaging ensures proper patient
positioning for each treatment. The radiation can be sculpted to fit the
shape of the tumor, improving accuracy, precision, and efficiency.
Additionally, Hoag’s Elekta machines deliver Volumetric Arc Therapy
(VMAT), an advanced technology that delivers radiation in single or multiple
arcs around the patient under
3D image guidance. The Hexapod iGuide Couch (6D) of the Elekta Versa HD
machine adjusts the patient during each treatment into the exact location
with submillimeter accuracy.
Rectal Cancer Clinic
The newly launched Rectal Cancer Clinic is a distinction of Hoag’s
program and an advantage to patients. Launched in 2017, the Clinic integrates surgeons, medical oncologists,
radiation oncologists, pathologists, radiologists, and the nurse navigator
to collaboratively review and develop individualized treatment plans for
all new rectal cancer cases. The team developed an algorithm to standardize
the optimal process for patients to be seen and evaluated. A result of
the Clinic is improved and accelerated communication among multiple providers,
ensuring each patient’s treatment is coordinated and streamlined.
CLINICAL RESEARCH
Through the Institute’s Developmental Therapeutics Program in alliance
with USC Norris Comprehensive Cancer Center, Hoag has opened several phase
I and II clinical trials for which patients with colorectal cancer may
be eligible. The clinical trials below have opened at Hoag. For a list
of trials currently open, please contact Leila Andres, M.S., at 888-862-5318.
(107-18) 0C-17-5: A Phase 1b/2 Study of BMS-813160 in Combination with
Chemotherapy or Nivolumab in Patients with Advanced Solid Tumors (Phase
1b/2 clinical trial, appropriate for patients with colorectal or pancreatic cancer)
(133-17) 3C-16-5: A Multicenter, Randomized, Open-label, 3-Arm Phase 3
Study of Encorafenib + Cetuximab Plus or Minus Binimetinib vs. Irinotecan/Cetuximab
or Infusional 5-Fluorouracil (5-FU)/Folinic Acid (FA) /Irinotecan (FOLFIRI)/
Cetuximab with a Safety Lead-in of Encorafenib + Binimetinib + Cetuximab
in Patients with BRAF V600E-mutant Metastatic Colorectal Cancer (Phase
3 clinical trial, appropriate for patients with colorectal cancer.)
(187-17) 0C-17-11: Phase 1 trial of ZW25 in patients with locally advanced
(unresectable) and/or metastatic HER2- expressing cancers (Phase 1 clinical
trial appropriate for patients with HER2 expressing cancers.)
(214-17) OC-17-17 A Phase 1/2 First-in-human Study of BMS-986258 Alone
and in Combination with Nivolumab in Advanced Malignant Tumors(Phase 1/2
clinical trial, appropriate for patients with advanced malignant tumors.
(155-17) 0C 17-1: Phase I Multicenter Study of the Safety of Pharmacokinetics
and Preliminary Efficacy of CBT- 101 in Subjects with Advanced Solid Tumors
and C-Met Dysregulation (Phase 1 clinical trial appropriate for patients
with advanced solid malignancies)
SCREENING AND HIGH RISK SERVICES
With regular screening, colorectal cancer can be prevented or detected
at an early stage. Hoag Family Cancer Institute recommends routine screening
colonoscopies for men and women beginning at age 50 with subsequent intervals
for retesting as determined by a physician based on various risk factors.
The Hoag Endoscopy Center offers high quality outpatient care; their Adenoma
Detection Rate is above national averages.
Hoag’s interventional gastroenterologists are specially trained and
skilled in advanced endoscopy techniques for removal of very large pre-cancerous
polyps and in some cases, early stage cancers. The use of colonoscopy,
endoscopic mucosal resection (EMR), and endoscopic submucosal dissection
(ESD) means polyps that only a few years ago would have required surgery
can now be successfully removed endoscopically. Hoag is an early adopter
of the recently FDA-approved Full Thickness Resection Device (FTRD®
System) made by Ovesco for the removal of early cancers or defiant polyps.
Patients with a family history of colorectal and other cancers are referred
to Hoag’s Hereditary Cancer Program and possible genetic testing
through the Richard J. Flamson Hereditary Screening Program. This is a
critical component of Hoag’s comprehensive colorectal cancer care
– the aim is to understand how each patient’s cancer should
be treated and how cancer risk should be managed based on their immunohistochemistry
and genetic profile.
SUPPORT AND EDUCATION
Diane Eadie, R.N., GI cancer nurse navigator, plays a crucial role in the
program by coordinating patients’ multidisciplinary treatment plans;
she is a constant for patients throughout diagnosis, treatment, and survivorship
and helps remove any potential barriers to care. Diane also provides emotional
support and links patients to helpful resources including the Oncology
Nursing Hotline, Integrated Cancer Support Services, and the monthly GI
Cancer Support Group, which meets at the Patty & George Hoag Cancer
Center in Newport Beach.
Hoag provides special resources for colorectal cancer patients who need
a colostomy including a monthly Ostomy Support Group as well as specialized
enterostomal nurses who provide pre-op education to patients and help
them appropriately manage stomas through Hoag’s Ostomy Care Program.
For more information call:
949-722-6237