Cancer Specialists Collaborate to Analyze Treament Options: Advanced Techniques Refine Choices
Bill Mussone's blood tests showed he was anemic, so his physician did some more testing. "He came out looking like he'd seen a ghost," Mussone said. His doctor had seen cancer. Mussone's next step was a visit to a surgeon, and the message he received there was just as life-changing. "You'll need a colostomy, I'm 100 percent certain," was what Mussone heard.
The surgeon was telling him that the treatment to remove Mussone's rectal cancer would leave him without the ability to have a normal bowel movement, that he would have to live the rest of his life with a bag attached to his abdomen to do that job. "I thought my life was over. I literally felt the weight of the world on my shoulders," Mussone said.
The news was particularly hard for Mussone, then 58, because he had recently married. The wedding had been a joyously large celebration. And Mussone, an endodontist, was looking forward to retirement in just a handful of years. "Now," he said, "I was faced with not surviving."
Mussone, however, was not ready to accept that first opinion. "It's easy just to say, 'We're going to take your rectum out,'" Mussone said. "It's much harder to do the analytics, to look at alternatives." He found Mark Welton, MD, who leads the colorectal cancer team at the Stanford Cancer Center. It is one of only 65 cancer centers in the U.S. designated for major funding by the National Cancer Institute because of its multidisciplinary research programs committed to improving the clinical care of cancer patients.
As an innovator and expert in surgical techniques to help patients with colorectal cancer avoid colostomy, Welton helped develop the American College of Surgeons program to improve colorectal surgery and serves on the executive board of the American Society of Colorectal Surgeons. The radical surgery Mussone was told he had to have "is not an unreasonable recommendation from a general surgeon," Welton said. In Mussone's case, however, Welton thought the cancer was small and accessible enough to treat with a more conservative surgical removal that would spare Mussone a colostomy.
"He was so kind-hearted," Mussone said. "I walked out feeling hopeful. The physicians I met at Stanford just lifted my spirits."
More detailed understanding
Colorectal cancer is the third most common malignant tumor type worldwide and the second leading cause of cancer deaths (irrespective of gender) in the United States, according to the National Cancer Institute. Atypical growths in the intestines can hide in the folds of the body's 25 to 28 feet of intestines. At first, physicians had to rely on X-rays, using barium to detect colon problems. Not until the 1970s did techniques and devices emerge that could not only visualize in better detail the entire length of the colon, but could also find and remove polyps−benign growths that can develop into cancerous tumors.
As with many other illnesses, early detection is crucial to successful treatment. Colorectal cancer's mortality rate has declined steadily in recent years, the decrease aided by a public awareness and acceptance of colonoscopy that increased how many people are screened. Cancer, however, remains in many people's view a single entity distinguished only by its location. As a group, cancers do share one trait: they are abnormal cells that grow without control. Within that broad description, however, is a multiplicity of cancers with individual characteristics that determine location and behavior.
I thought my life was over... The physicians I met at Stanford just lifted my spirits.
Some colorectal cancers, Welton said, can become quite large but not spread anywhere else. Some go through the lymphatic system to the lymph nodes and the bloodstream. Welton uses a metaphor when he talks with patients about treatment. "If you're trying to figure out how to get to San Francisco, what you really want to know is if you have a car. If the cancer is in the lymph nodes, we can remove that. But we also know that if it’s there, it has a car," Welton said.
If the cancer has moved elsewhere, or grown deeply into the colon wall, then any surgical treatment is enhanced with chemotherapy, a way to take the air out of the tires of a cancer that might have already escaped to another location before surgery, Welton said.
Some of Mussone's colorectal cancer cells had apparently found their way into his lung before his primary tumor was removed, although growing so slowly they were not discernable until three years after his first surgery. "It was too small to be seen and the chemo didn't kill it," Welton said. When discovered, the tiny lesion was removed. Two years later, another bit of colorectal cancer showed up in Mussone's lung and was again removed. Since Mussone's first meeting with Welton, his cancer has not reappeared in its original location.
From the very start, Mussone's treatment was a collaborative enterprise. Stanford's history of innovative cancer treatment springs in large part from its tumor boards, Welton said. "You've got 15 other physicians in the room, all experts, who might say, 'It's time for you to push the envelope. Our radiation is better now, our chemo is better now. This is something we might have always thought non-operative, but maybe we need to push this.' "
Disease-specific tumor boards meet weekly. A board may include surgeons, medical oncologists, radiation oncologists, pathologists and hematologists. Mussone's treatment has involved several physicians, including Welton, medical oncologist George Fisher, radiation oncologist Albert Koong and thoracic surgeon Richard Whyte.
As we work together in the same environment, we gather momentum and energy and excitement and this helps us take better care of patients and improve their overall experience.
"Many of the successes we've had in cancer management come directly from the successful interaction of the specialists," said Richard T. Hoppe, MD, Stanford's Chair of Radiation Oncology. "And the majority of cancers we treat at Stanford we treat with more than one modality."
"I think it's well documented," Welton said, "that as we work together in the same environment, we gather momentum and energy and excitement and this helps us take better care of patients and improve their overall experience."
Mussone's treatment also included chemotherapy and radiation. The Stanford Cancer Center was one of the first medical centers to use chemotherapy before surgery to prep the cancer cells to be more sensitive to radiation that would follow. The approach has proven very effective. The Center's radiation therapy is directed by the most advanced, most precise three-dimensional imaging that protects healthy tissue.
As their understanding of cancer increases, physicians hope that more and more kinds of cancer will be manageable in the same way that certain chronic illnesses−like hypertension, diabetes and coronary artery disease−will be kept in check. "You might not be able to cure a cancer," Welton said, "but you could control it so it doesn’t shorten your life."
Lower Your Risk for Colorectal Cancer
- Build meals that are low in fat and rich in fruits, vegetables and other high-fiber foods. Exercise is also beneficial.
- If you have a family history of colorectal cancer, let your doctor know. About 20 percent of colorectal cancers are believed to be genetically transmitted.
- At age 40, ask for an annual fecal blood test.
- At age 50, ask for a flexible sigmoidoscopy or colonoscopy screening.
When to See Your Doctor
Symptoms of colorectal cancer can include:
- blood in stool
- anemia, fatigue, weakness
- diarrhea, abdominal pains, cramps, constipation
- changes in bowel habits
What Can Cause Colorectal Cancer?
The causes of most colorectal cancers are not definitively known. Anal cancer, however, has shown a high association with infection by the human papilloma virus (HPV), the same virus that can be responsible for cervical cancer in women. Stanford's colorectal cancer specialist, Mark Welton, advocates that men and women at high risk for the disease be screened with a tissue sample similar to the cervical tissue test women routinely undergo. When that test, commonly known as a Pap smear, became routine, 40 women in 100,000 died of cervical cancer, Welton said. Now, the number is 6 to 8 per 100,000.
Mussone has been watched quite carefully, of course, and his two recurrences were disappointing, Welton said, "but fighting cancer is a war, not just one battle. The key players are the physicians who take care of you−and a patient who bounces back after a couple of bumps in the road."
Welton looks at Mussone and sees someone who is being treated by a group of physicians who know his case well and who watch him closely. "Maybe we do take little things out every three or four or five years," Welton said, "but he's getting more years of life."
Mussone, who knows how different his life would be if he had had a colostomy, is clearly on his best game. "I'm on board for whatever," Mussone told Whyte at a recent check-up. "You keep saving my life!"
Managing cancer will be much easier as research works out techniques to identify whether a particular patient's cancer is likely to recur and what might be the most effective chemotherapy. Some of the most advanced work is under way at Stanford. Welton, Fisher and Koong are collaborating with Stanford medical oncologist Hanlee Ji, senior associate director of the Stanford Genome Technology Center to test for those predictors with molecular inversion probe technology, the most advanced analytic tool now available.
Mussone has taken his recovery as he has done things all his life. "I've always been one to take the bull by the horns," he said. He works out with a trainer twice a week, watches his diet and enjoys the couple of days a week he spends at work. "I'm not focused on dying," he said. "I'm hopeful—my plan is to die of old age."