By: Christina Wu, MD; Associate Professor, Department of Hematology and Medical Oncology at Emory University School of Medicine
An active, previously healthy 50-year-old man, with no family history of colorectal cancer, presented to an urgent care center after experiencing bloody stools for four or five months. This exam prompted a colonoscopy, his first, at a local hospital, where a 3.7 cm rectal mass was discovered and biopsied. Given a diagnosis of rectal adenocarcinoma, he referred himself to Winship Cancer Institute of Emory University.
In February 2020, he was seen by the GI medical oncologist with consultations with the colorectal surgeon and GI radiation oncologist. A series of imaging tests were performed — CT scans of the chest and abdomen and a MRI scan of the pelvis with a specific rectal cancer protocol — which found the cancer had grown into the outermost layers of the rectum and spread to one enlarged lymph node around the tumor.
Following the Winship at Emory protocol, the man’s case was presented to Winship’s rectal tumor board: a specialized team of GI pathologists; GI medical, surgical, and radiation oncologists; and a patient navigator who meet regularly to review all rectal cancer patients at Winship and determine the best treatment and treatment sequence. Given this patient’s T3N1 staging, the question was how to sequence chemotherapy and chemoradiation before surgery.
The recommendation was that the patient begin with chemotherapy, followed by chemoradiation, then by surgery.
Within four weeks of his cancer diagnosis, the patient began a three month FOLFOX chemotherapy regimen: a combination of 5 Fluorouracil and oxaliplatin. He tolerated treatment well, continuing to work at home (due to the current pandemic), and enjoying activities with his wife. After completing chemotherapy alone, a scan showed that his tumor had shrunk to 3.2 cm, but more importantly, his cancer was downstaged to T2N1.
He then began five and a half weeks of chemoradiation as scheduled. This consisted of taking an oral chemotherapy pill, capecitabine, twice daily, Monday through Friday, in combination with daily (Mon-Fri) treatment of radiation for a total of 50.4 Gy. Again, he tolerated treatment very well, with no interruption in his work or daily activities. Ordinarily, in addition to going to the radiation center daily, patients come to the clinic weekly to see medical oncology for follow-up but for his convenience and for the extra protection Winship was offering during the COVID pandemic, Winship at Emory physicians were able to see him in person every other week, meeting through telemedicine on alternate weeks.
In November 2020, at the end of chemoradiation, a colonoscopy, CT scans and pelvic MRI showed that his cancer had completely disappeared and that the lymph node was no longer enlarged.
Pictured above: MRI study of before/after treatment; MRI pelvis (rectal cancer protocol)
Although the original treatment plan had included surgery following chemotherapy and chemoradiation, the clinical team now presented another option to the patient. The team could go ahead with surgery to remove the area where the cancer had been — or the patient could forego surgery, and begin a multi-year period of intense surveillance.
After extensive discussion with his clinical team, during which they compared the different approaches and answered all his questions, the patient chose the watch-and-wait option. He was, in fact, quite pleased with this possibility. Like many individuals who receive a diagnosis of rectal cancer, he had worried that rectal cancer surgery might result in the need for an ostomy, which he believed would have been life-changing for him, given his relative youth, activity, and hopes for travel once the pandemic ends. (Both he and his wife were vaccinated during his treatment without problems.)
Thus, starting from November 2020, the patient began the close surveillance protocol, considerably more intense than for patients not under watch-and-wait. He comes to Winship every three months for a physical examination, laboratory workup, and flexible sigmoidoscopy. Every six months he will receive a rectal MRI in addition. This will continue for at least five years. His first tests in February 2021 were completely negative, with no evidence of cancer. He is cancer free, and has avoided a life-changing surgery. He has now returned to the life he had before his diagnosis of cancer.
Why did he do so well? Only about 15 percent of patients with stage 2 or stage 3 rectal cancer achieve a complete response to chemotherapy and chemoradiation alone. Seeking to understand this difference, Winship clinicians and scientists currently are looking at molecular changes in the tumors of patients who achieve complete response compared to the tumors of those who do not. Understanding this could lead to more individualized treatments.
They also want to understand why approximately 30 percent of patients who experience a complete response to chemotherapy/chemoradiation nonetheless have a recurrence of their cancer. What is different about these patients and how could treatment address any such differences? (Other research ongoing at Winship includes a number of clinical trials for stage 1, 2, and 3 rectal cancer.)
Clinically, the intense surveillance schedule which this patient is now following is designed to catch any recurrence as early as possible, so that they may then proceed with their curative surgery.
And for the more than 60 percent of patients for whom complete response continues, the watch-and-wait protocol means avoiding surgery that would not have been necessary. That is what this patient is celebrating now.
Our Colorectal Cancer Team
Winship Cancer Institute of Emory University’s colorectal cancer program offers a multidisciplinary approach. Our team of experienced specialists in gastroenterology, colorectal surgery, radiation therapy and medical oncology deliver a comprehensive and coordinated approach to treating colorectal cancer.
Our multidisciplinary tumor board meets weekly to discuss individual cases, review treatment plans, and assess clinical trial eligibility. Personalized care plans are developed based on the most current discoveries in colorectal cancer treatment, and research including genetic or molecular testing for specific gene mutations.
To refer a patient to any one of our Winship Cancer Institute locations, call our Referral and Appointment Center at 1-888-WINSHIP or 404-778-1900.
Winship Cancer Institute of Emory University is committed to the continued health and safety of all patients. During this time, we are taking all necessary precautions to screen for COVID-19 and to prevent its potential spread. We continue to monitor the evolving COVID-19 situation and are working with experts throughout Emory Healthcare to keep your patients safe. For the most up-to-date information for our referring partners, click here.
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