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