100 NICOLLS ROADSTONY BROOK, NY 11794-9228

Clinical Care | Research | Education April 2015 | Number 2

CancerTodayStony Brook

Stony Brook’s Multidisciplinary Colorectal Oncology Team

“I’m lucky. My doctor scheduled a follow-up colonoscopy for me in November 2010. Onmy original colonoscopy, they found a polyp, which was taken care of. From the secondone, I was diagnosed with stage I rectal cancer. My doctor recommended Dr. Bergamaschiand Stony Brook Cancer Center. Dr. Bergamaschi removed the tumor robotically, leavingmy colorectal system intact and preserving my quality of life. I’m grateful every day thatI was sent to Dr. Bergamaschi. I am now four years cancer free and I feel great.” – Mike K.

TREATMENT:

The patient received an intersphincteric resection (ISR), which is aprocedure indicated for rectal cancers abutting the dentate line. Thesurgeon removed the internal anal sphincter while preserving the externalanal sphincter and levator ani muscles. ISR is a delicate surgical procedurewith a hand-sewn coloanal anastomosis. It is considered the only alternativeto removing the anus with a permanent colostomy.

Sharing My Story

Illustration of the tumor

Physicians always stress to patients the importance of early detection for cancer,advising that the sooner cancer is foundand treatment is started, the better the outcomes. But for colorectal cancer, there’sa unique story to tell. Proper screeningfinds cancer in the early stages, when it’smost treatable. It detects the adenomatouspolyps that can be precursors to cancerand provides an opportunity for those precancerous growths to be eliminated.Cancers of the colon and rectum canliterally be stopped from developing.

Colorectal carcinoma is a neoplastic growthof the mucosa of the lining of the colon and rectum. Most of these cancers areadenocarcinomas and nearly 90 percent of these tumors occur in patients after theage of 50. Colorectal cancer is the thirdmost common cancer diagnosed and totalsnearly 133,000 cases per year in the U.S.,according to the American Cancer Society(ACS). This breaks down to approximately93,000 cases of colon cancer and almost40,000 cases of rectal cancer.

What are the signs and symptoms?

Unfortunately, colorectal cancer is oftensymptomless, though patients should

report any of these symptoms to theirprimary care physician for possible follow-up:

• Blood in the stool• A change in bowel habits• A change in the size, shape or caliber

of the stool• Abdominal pain• Unexplained weight loss

Parameters for Screening

Recommendations by the ACS are based onthree risk categories: average, moderate andhigh. While gender does not seem to be a riskfactor, age is, and risk increases after age 50.Average risk is defined as all people 50 yearsor older who do not have any personal orfamily history of adenoma, carcinoma orpredisposing disease. This categoryencompasses 70 to 80 percent of the U.S.population. The recommendations state thatpeople who are considered average riskundergo screenings between ages 50 and 75.

Individuals at high risk should start screeningsearlier and have more frequent follow-ups.People considered to be at higher risk includethose with a family history of polyps, coloncancer or uterine cancer; individuals with inflammatory bowel disease; anyone with a

stonybrookmedicine.edu

Contact Information

Stony Brook University Cancer Center

3 Edmund D. Pellegrino RoadStony Brook, NY 11794-9452(631) 638-1000

Radiation Oncology

(631) 444-2200/444-2210

Medical Oncology

(631) 638-1000

Colorectal Cancer Screening and Treatment

IN THIS ISSUE

Message From the

Deputy Director

Prevention and Detection of

Colorectal Cancer

Focus on: New Clinical

Program

Multidisciplinary Colorectal

Oncology Team

Stony Brook University/SUNY is an affirmative action,equal opportunity educator and employer.15021097H ©2015

Stony Brook Cancer Today

Editor-in-Chief

Samuel Ryu, MD

Produced by:

Office of Communications Stony Brook Medicine

Correspondence to:

Joan Garvey, Communications SpecialistOffice of Communications188 Belle Mead Road East Setauket, NY 11733-9228Photographers: John Griffin, Office of UniversityCommunications and Jeanne Neville, MediaServices

At Stony Brook University Cancer Center,the latest protocols and treatments forcolorectal cancer are offered by theColorectal Oncology Management Team. This multidisciplinary approach ensurescoordinated care tailored to the needs ofeach patient.

Colorectal surgeons perform robotic-assistedsurgery in addition to open surgery andlaparoscopic surgery. Each type of surgery hasa purpose and each case is evaluated todetermine the best course of treatment.

Robotic-Assisted Surgery

Stony Brook Medicine acquired the da Vinci®

Surgical System — the first system approvedby the Food and Drug Administration in 2000.In fact, our medical center was the first onLong Island to acquire the most technicallyadvanced model of the robot.

Robot-assisted surgery has added a newdimension to surgical options for patients withcolorectal cancer. The surgeon is in full controlof the robotic system, which translates his orher hand movements into smaller, more

personal history of polyps; and persons with inherited syndromes such as familialadenomatous polyposis and hereditarynonpolyposis colorectal cancer, also known asLynch syndrome. In addition, recent studiesshow that because African-Americans have ahigher risk of colon cancer, they may want tostart screenings at age 45.

“Researchers at Stony Brook and many other U.S.and international institutions continue to delveinto the causes, prevention and treatment ofcolorectal cancers. But it’s important to rememberthat research has proven that screening of coloncancer saves lives. Having precancerous polypsremoved before disease develops is an importantintervention that reduces the chances of havingcolon cancer.” – Vincent Yang, MD, PhD, Simons Chair and Professor,

Department of Medicine

The Stony Brook Approach

At Stony Brook, colonoscopies are consideredthe gold standard in screening for colorectalcancer. Two types of colonoscopies areoffered: optical or traditional colonoscopy andcomputed tomography (CT) colonoscopy, alsoknow as virtual colonoscopy. For details onthese screening procedures, turn to page 2.

Early detection is key

precise movements of tiny instruments insidethe patient’s body. Surgeons first make a fewsmall incisions, similar to what’s done intraditional laparoscopy. But, the robotic systemfeatures a magnified 3D high-definition visionsystem and special wristed instruments thatbend and rotate far greater than the humanwrist. As a result, the robotic system enablesthe colorectal surgeon to operate withenhanced vision, precision, dexterity andcontrol. And this technique has proved itssafety profile in both colon and rectal surgery.

“The robot represents a major advance incolon and rectal surgery that offers patientsmore benefits than the conventional surgicalapproach,” said Roberto Bergamaschi, MD,PhD, Professor of Surgery, and Chief,Division of Colon and Rectal Surgery. “Inaddition, we are the first to have publishedevidence that robotic-assisted surgery forrectal cancer provides a radial resectionmargin larger than the margin laparoscopicor traditional surgery can offer. This is veryimportant, because radial resection margin isthe metric that predicts survival.”

Stony Brook Cancer Today

Focus OnNew Clinical Program

cancer.stonybrookmedicine.edu

Virtual colonoscopy. Also known ascomputed tomography (CT) colonography, virtual colonoscopy is a safe, highly accurateminimally invasive CT imaging examination of the entire colon and rectum. It is a well-tolerated exam that takes about 10 minutes to complete. Its goal is the same as that oftraditional colonoscopy: to identify polyps andcancers in the colon. Polyps have been shownto be the precursor of most colon cancers, and the goal of virtual colonoscopy is to findthese potentially dangerous polyps before they become actual cancers.

Virtual colonoscopy does not require anysedation, and therefore patients can drivethemselves to and from the procedure andimmediately return to work. Virtual colonoscopyuses only a small very flexible tube with only the tip inserted, which essentially eliminatesthe risk of colon perforation and complications.At the end of the exam, the carbon dioxideused to distend the colon is decompressed,giving patients immediate relief. In addition,virtual colonoscopy involves minimal radiation.

Candidates for Virtual Colonoscopy

Virtual colonoscopy is appropriate for allpatients who are candidates for colon cancerscreening. It is especially useful for patientswho are at risk and cannot undergo traditionalcolonoscopy or who have had a priorincomplete colonoscopy.

Expected Outcomes and Follow-Up

Ninety percent of average-risk patients whoundergo virtual colonoscopy will have nopolyps detected and will not need furthertesting. These patients should return forroutine screening in five years. Ten percentwill have one or more polyps greater than 6 mm detected and will need to undergooptical colonoscopy to remove the polyps. In some of these patients, where the risk ofundergoing colonoscopy may be greater thanthe risk of leaving the polyp in place, short-term follow-up with a repeat CT colonographyin three years may be recommended.

Virtual colonoscopy screening requires bowelpreparation the same way the traditionalmethod does. A benefit to the virtual exam is that it can detect unsuspected medicalproblems outside the colon. While only 1 in300 patients who has a virtual colonoscopyscreening will have colon cancer, up to 1 in 200 patients has been shown to have an unsuspected kidney, lung or lymph node cancer.

For those who refuse or cannot endureeither an optical or virtual colonoscopy, anannual immunochemical fecal occult bloodtest (iFOBT) is strongly recommended (seetable below).

ADDITIONAL SCREENING OPTIONS

Message From theDeputy Director

Samuel Ryu, MDDeputy Director, Clinical AffairsStony Brook University Cancer Center

Anticipation is growing among the CancerCenter physicians and staff as we count down in months — instead of years — to the opening of the Medical and ResearchTranslation (MART) building next spring. Thedream is tangibile: the walls now surround a portion of the steel frame and indoorconstruction is progressing.

We are also actively expanding our innovativecancer programs and creating new ones as we hone our strategic plan. One major focus is on prevention and early diagnosis throughscreening programs. We successfully launchedthe Center for Lung Cancer Screening andPrevention, which uses a computed tomography(CT) scan instead of an x-ray for screening ofindividuals at high risk. When a tumor isdetected early, curative treatment options areavailable with either conventional or cutting-edge technologic therapy for the best outcomes.These advanced multidisciplinary treatments arebeing performed by physicians with disease-specific expertise for personalized care.

This issue is dedicated to the colorectal cancerscreening program at Stony Brook, where bothoptical and virtual colonoscopies are performed.I am proud that our team of experts continues to develop the program through research andeducation.

I personally invite you to discuss any aspect ofour cancer program with me. The Cancer Centerstaff and I look foward to working as a partnerwith you to optimally serve the community.

New Cardio-OncologyProgram Instituted

Did You Know?Stony Brook was one of the originalpioneers in virtual colonoscopy. Thesoftware used to read virtual colonoscopydescribed in the landmark research paperpublished in 2003 by New England Journalof Medicine (NEJM) was invented at StonyBrook and continues to be used today.

An innovative program, partnering the expertise of physicians from Stony Brook University HeartInstitute and Stony Brook University Cancer Center,has been established to address the unique need forcardiovascular care in patients with cancer. Patientswith cancer require careful attention for potentialcardiovascular complications at all stages of theircancer therapy, from initial diagnosis, duringsubsequent treatment, and well beyond completionof therapy. Patients may already have known orundiagnosed cardiovascular disease at the time of a cancer diagnosis, putting them at higher risk foradverse effects from cancer therapy. Even in thosewho do not have heart problems, such patients maydevelop heart dysfunction during cancer therapy. For those who have completed treatment, there areongoing long-term cardiac concerns.

With the Cardio-Oncology Program, operationsbetween the Heart Institute and Cancer Center arestreamlined, coordinated and facilitated, to safelyadminister care to this patient population. HeartFailure Cardiologist Michelle Weisfelner Bloom, MD,and Medical Oncologist Lea Baer, MD, are the co-leaders of this initiative.

“The Heart Institute has always cared for patientswith cancer on a case-by-case basis. Now, as weembark on this exciting collaboration, all patientswill have access to early surveillance, comprehensiveimaging and personalized cardiac care to maximizethe chances for optimal outcomes,” said Dr. Bloom.“By creating a team of cardiologists and oncologists,we will work together to improve disease prognosisand patient survival. This initiative furthers ourcommitment to focus on novel, comprehensive waysto benefit our patients.”

The program offers close monitoring of patients with,or at risk for, heart-related complications throughclinical evaluation, blood tests, and state-of-the-artnon-invasive imaging at the Heart Institute underthe direction of Smadar Kort, MD, Director,Cardiovascular Imaging. “This is one of the mainadvantages of an academic medical center. Thesepremier services are all offered through Stony Brookfacilities and we can build on that by collaboratingwith our colleagues in other medical specialties,”said Dr. Baer.

For more information or to schedule a consultationwith the Stony Brook Cardio-Oncology Program, call(631) 444-9746.

Lea N. Baer, MDMedical Oncologist

Michelle Weisfelner Bloom, MDCardiologist

Prevention and Detection of Colorectal Cancer with Screenings at Stony Brook Cancer Center

While people often dread undergoing acolonoscopy, it is important to know thatrecent changes in both preparation andprocedure make it a gentler experience. Now, a smaller amount of liquid with animproved taste is used for bowel preparation.Also, patients undergo a short, fast-working,deep sedation that has minimal side effects,including no memory of the procedure.Because patients are sedated, they will needto arrange for someone to drive them home.

When Cancer Is Diagnosed

At Stony Brook, when cancer is diagnosed,the patient is immediately referred to ourcolorectal surgeons, who often see thepatient at the time of the colonoscopy.Immediate follow-up is arranged so that thepatient can have radiology tests performed in an expedited manner. The patient will then undergo expert laparoscopic removal of the tumor and the patient is referred tomedical oncology to discuss if any furthertherapy is indicated. The patient receivescounseling regarding a more intensivesurveillance program and may be referred for genetic testing. Information is givenregarding more aggressive screening forfamily members.

Optical colonoscopy. At Stony BrookMedicine, patients who are ages 50 to 75and deemed “average risk” or have nosignificant health risks are scheduled for anoptical colonoscopy through the Division ofGastroenterology and Hepatology. Thisscreening procedure has two objectives:Find polyps or tumors throughout the colonand rectum, and perform a polypectomy onany size polyp that is detected. Removingthe polyp reduces the risk of developingcolorectal cancer. When a precancerouslesion is found, an optical colonoscopy isneeded every three to five years. If thescreening reveals no abnormalities, thepatient can wait 10 years to have a follow-upcolonoscopy, assuming there are no medicalcomplications during that same time period.

Individuals who have not had their initialcolonoscopy and who have complicatedmedical histories are scheduled for an officevisit with a board-certified gastroenterologistin the division prior to a colonoscopy. Thereare several reasons why an individual mayneed to have a colonoscopy before age 50,including rectal bleeding, anemia and achange in bowel habits. Patients shoulddiscuss these concerns with their primarycare physician or gastroenterologist.

SCREENING OPTIONS: For the detection of precancerous polyps and cancer

Test

Optical Colonoscopy

(Screens entire colon)

Virtual Colonoscopy

(Screens entire colon)

Test

Immunochemical

Fecal Occult Blood

Test (iFOBT)

Multitarget Stool

DNA Testing

(Cologuard®)

Advantages

• Can look at entire colon and rectum• Allows for polyps to be taken out at time of exam• IV sedation used for comfort

• Can look at entire colon and rectum• Patients can return to work/activity following the

test, unless optical colonoscopy is required• No IV or sedation required

Advantages

• No bowel prep is needed• May be done at home• Most affordable option for uninsured patients

• No bowel prep is needed• May be done at home

Considerations

• Cleansing of the colon is required (bowel prep)• Sedation with recovery time; patient needs a single day off

of work• Patients need a driver to take them home

• Cleansing of the colon is required (bowel prep)• If a polyp is found, optical colonoscopy is required to

remove the polyp• CT images provide a limited view of other internal organs• No driver needed to take the patient home

Considerations

• Does not detect polyps at an early stage• May have false-positive and false-negative results• Colonoscopy is needed if test is positive for blood

• Better detection of advanced polyps than iFOBT• Colonoscopy is needed if test is positive• Cost is high

Description

The rectum and total colon are looked at using a flexible tube with a built-in camera and light called a colonoscope. Abnormal growths can be found and removed or biopsied.

A CT scan of the abdomen is done while gas (CO2) is put into the colon.Special computer software builds a 3D model of the total colon andrectum. This is viewed by a radiologist to look for colon polyps and cancer.

Description

This test checks for invisible blood in the stool and can be completed athome by collecting one stool sample. If blood is found in the stool, thismay be due to a polyp or cancer and more testing is needed.

This test checks for 7 DNA mutation biomarkers and 2 DNA methylationbiomarkers. A single stool sample is collected at home.

Frequency

Every 10 years

Every 5 years

Frequency

Every year

Intervaldetermined byphysician

Referring physicians or patients:

Call (631) 444-COLON (444-2656) for an optical or virtual colonoscopy.

Referring physicians:

Call (631) 638-2121 to schedule a virtual colonoscopy for your patient.