The Best Colorectal Cancer Treatment De-intensification Is Better Screening

Mark A. Lewis


April 27, 2022

This transcript has been edited for clarity.

Hello, Medscape! This is Mark Lewis and I'm speaking to you in March, which is Colorectal Cancer Awareness month. I'm wearing blue, which is the thematic color for this particular month and its cause and advocacy.

I feel really passionately about this month because, frankly, a medical oncologist like myself is the last person who should see a patient with colorectal cancer. I know there are many debates about screening. What is the best screening modality? Should we change the age at first screening? Of course, the US Preventive Services Task Force weighed in on that last year and shifted the age of first screening for the average-risk American population from 50 down to 45 years.

I'm not even here to talk about that; it is very nuanced. I'm here to talk about the best screening, which is the screening that gets done. In the past 2 years — and I think we can largely blame the COVID-19 pandemic here — we've seen a dramatic drop-off in screening.

I can only speak here to the institution where I work — Intermountain Healthcare — and the role I serve, which is as a gastrointestinal (GI) oncologist. I've seen screening drop systemwide by 50%, but I've seen the rate of stage III colon cancer rise 15%.

That pains me because so much of GI oncology of late, and in fact as recently as ASCO GI this year, has been about de-intensification of therapy. There is no drug in GI oncology that weighs on my conscience so much as oxaliplatin.

Literally from the first day of my fellowship, I was taught to treat that agent with an appropriate degree of respect and gravity because it is the bell that you cannot un-ring. If you inflict neurotoxicity, is almost always chronic and it certainly can be irreversible. In my mind, it's all about how an ounce of prevention is worth a pound of cure. The less oxaliplatin we can give, the better.

There was a wonderful and thoughtful presentation at ASCO GI about de-intensification of oxaliplatin. Much of that goes back to the IDEA study and risk stratification between T3N1 and T4 and/or N2 disease and the respective assignment of those patients to 3 vs 6 months of adjuvant chemotherapy. If we're going to split hairs, there seems to be some role for 3 months of CAPEOX in the low-risk stratum.

Regardless, the better-case scenario is not having stage III colon cancer at all. Here's where I think that colonoscopy in particular — and maybe I'm biased — has an almost unique role in oncology, not just as a screening modality but as a preventive modality.

A polypectomy, performed by a gastroenterologist or a general surgeon, is interrupting the adenoma-to-carcinoma sequence in a way that many other screening tests are not interfering with natural disease biology. A mammogram, for instance, can find a breast mass, but the mammography itself is not changing the natural history of that disease.

What I'm getting at is that it has been very understandable that patients have reverted to preferring fecal-based tests if they're going to be screened at all for colorectal cancer during the past 2 years. One other alarming thing I've seen is positive fecal tests not resulting in follow-up colonoscopies. That is an incomplete screen, and frankly, it frightens me that there are patients out there with positive fecal immunochemical test (FIT) tests who have not yet been scoped. Subsequently, I worry that they harbor, at the very least, advanced adenomas and possibly even occult cancers.

There are all kinds of statistics in oncology. Stalin said, "A million deaths is a statistic; a single death is a tragedy." As far as COVID-19 is concerned, we're about to approach that really grim milestone in terms of US mortality from COVID-19.

Again, I'm not here to talk about the direct impact of COVID-19, but rather its indirect impact. I really feel like the lesser attention to colorectal cancer screening, not only in March but over the past 2 years, is resulting in higher disease stages — at least that I'm encountering in clinical practice — and, thus, more need for chemotherapy.

I really would love to give less chemotherapy. I would love to give less oxaliplatin, in particular, and I'd like to inflict less damage. The precept of "first, do no harm" is awfully difficult for a medical oncologist to follow. I think by working with our colleagues, specifically in primary care and gastroenterology, we can potentially avert some patients needing chemotherapy at all. That is certainly my hope.

This is Mark Lewis for Medscape. I wish you the best of health.

Mark A. Lewis, MD, is director of gastrointestinal oncology at Intermountain Healthcare in Salt Lake City, Utah. He has an interest in neuroendocrine tumors, hereditary cancer syndromes, and patient-physician communication.

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