A colorectal cancer diagnosis can be scary for both patients and their families because it raises questions and uncertainty—from how to cope with the condition to learning about treatment options and making a plan for recovery and the road ahead. CTCA patient, Scott, and expert oncologists share their knowledge.
Patients recently diagnosed with skin cancer—including melanoma, the most aggressive type of skin cancer—may have countless questions about their health, from wanting to better understand their disease and treatment options to how treatments may impact their quality of life. CTCA patient, Pam, shares her experience of battling cancer.
Medicine wouldn’t be what it is today without clinical trials, which form the foundation of medical research. The goal of clinical trials is to test the safety and effectiveness of a new treatment approach or to determine whether existing treatments may be used in new ways. Hear how CTCA patient, Loaunda, decided to enroll in a trial.
At Cancer Treatment Centers of America® (CTCA), treating cancer isn't just a part of what we do, it's all we do. Our expert oncologists treat every stage, every day using advanced technologies and precision cancer treatment. We believe that cancer affects every person differently, and that every person can benefit from a unique, individualized care plan.
We believe that every cancer is as unique as the person fighting it. In this era of precision medicine, with treatment advances evolving on a regular basis, fighting cancer requires truly personalized care, delivered by experts trained in the complexities of a difficult disease.
Every year, about more than 95,000 new cases of colon cancer and nearly 40,000 new cases of rectal cancer are diagnosed. Learn what types of surgical procedures may be needed, different types of additional treatments, and how to manage during recovery.
Colorectal cancer affects all ethnic groups, and men and women almost equally. Learn about some of the innovative ways experts are treating colorectal cancer from Arturo Loaiza-Bonilla, M.D., Chief Medical Officer at Cancer Treatment Centers of America® (CTCA) in Philadelphia.
Seeking a second opinion at CTCA may help you discover additional treatment options for your type and stage of cancer, or confirm a current treatment approach. We are here to help you understand your cancer treatment options, so you feel confident in the care you choose.
Colorectal cancer treatments often cause side effects that affect your quality of life. In severe cases, these challenges may make you feel too sick to continue treatment. That’s why it is important to work with a multidisciplinary team of cancer experts who will include evidence-informed supportive care therapies, like nutrition, naturopathic support and pain management, in your care plan to help maintain your strength, endurance and well-being during and after treatment.
Depending on the depth and size of the tumor, some patients may require a colostomy or ileostomy bag after surgery to divert waste while the body heals. These bags may cause anxiety, depression or lack of confidence for many patients. Talking with a mind-body therapist trained to work specifically with cancer patients in managing psychological and emotional challenges may help patients address and overcome their concerns. Oncology nurses may also help educate patients on how to manage a colostomy or ileostomy bag and take care of their personal hygiene.
Colorectal patients may experience pain, either from the tumor itself or from treatment. In fact, one in three patients continues to experience pain after treatment. To alleviate post-operative pain, oncology-trained pain management physicians may recommend implanted pain pumps, physical therapy, chiropractic care and, in some instances, prescription medications to keep you comfortable and help you return to normal activities.
While prescription pain medications may be necessary, non-pharmaceutical options also may help colorectal cancer patients manage their pain levels. Acupuncture may help to reduce pain and nausea for patients undergoing chemotherapy. Ariculotherapy, which involves stimulating the outer ear to improve healing, may also help. Massage and chiropractic treatment are other options that maybe integrated into your care plan to reduce pain and improve quality of life.
Eating may be difficult for some patients undergoing colorectal cancer treatment. Nausea, acid reflux, bloating and diarrhea are some of the most common symptoms these patients experience. In a growing number of cancer hospitals, naturopathic providers work closely with medical oncologists in assessing patients’ quality-of-life needs, suggesting natural and non-toxic therapies that may help reduce certain side effects of colorectal cancer and its treatment. Dietary supplements, vitamins and herbal preparations, in particular, may help reduce stress to the gastrointestinal system.
Treating colorectal cancer may lead to weight loss, diarrhea, constipation and nausea, and it may impair your ability to eat comfortably. To help your body get the nutrition it needs to heal, your oncologist may consult with gastroenterologists, registered dietitians and naturopathic providers in developing a care plan that includes strategies to achieve balanced nutrition and healthy digestion. This plan may include supplements, vitamins and various dietary approaches to help you stay strong throughout treatment.
Food has a significant impact on your entire body, particularly your colorectal health. Research has shown that a diet high in fiber, including whole grains and fresh produce, and low in red meat and alcohol may reduce colorectal cancer risk or recurrence. Eat at least five servings of fruits and vegetables every day, reduce or eliminate processed foods, particularly red meat like bacon or hot dogs, and reduce alcohol consumption.
Oncology rehabilitation may help improve your strength and endurance and help you regain your independence. Along with exercise, occupational therapy may help you relearn how to perform daily tasks and activities. Getting back to your physical well-being may lift your spirits and reduce anxiety and depression.
Finishing treatment is an exciting time for many cancer patients, but it may also come with an array of confusing emotions and challenges. It is important to nurture your emotional well-being. Therapists, spiritual advisors and support groups may help you cope with your feelings. It is also important to keep up with your follow-up appointments and notify your oncologist of troubling side effects or concerns that may arise.
How integrative cancer care may help maintain quality of life
Skin cancer affects more than 3 million Americans every year, with melanoma accounting for approximately 77,000 of those cases. Learn about the surprising places where skin cancer can be found, who’s at risk, and the latest treatments.
Learn about the most common type of cancer, skin cancer, including the rarest but most dangerous type, melanoma, from Laura Farrington, D.O., Medical Oncologist at Cancer Treatment Centers of America® (CTCA), in Chicago.
Seeking a second opinion at CTCA may help you discover additional treatment options for your type and stage of cancer, or confirm a current treatment approach. We are here to help you understand your cancer treatment options, so you feel confident in the care you choose.
Melanoma patients may find that certain supportive care therapies, such as nutrition therapy or naturopathic support, help boost their overall well-being and quality of life as they undergo treatment and transition to recovery. More and more cancer care teams are staffed with multidisciplinary experts in nutrition, naturopathic support, mind-body medicine, oncological rehabilitation and other supportive care disciplines to help patients manage the impact side effects may have on their strength and stamina.
Many patients experience pain and fatigue after surgery to remove melanoma and nearby lymph nodes. A number of non-pharmaceutical approaches may help both reduce these side effects, helping you get back to feeling more like yourself. Evidence-informed therapies such as acupuncture, massage, mind-body medicine and certain forms of oncological rehabilitation may, over time, help you feel more energized and function more normally. Talk with your care team about ways to manage post-operative pain and fatigue.
Lymphedema is a common side effect of surgery to treat melanoma. It typically occurs after lymph nodes have been removed, causing a buildup of fluid in the tissue. The most obvious symptom may be a swollen arm or leg. To reduce swelling and discomfort, your care team may recommend that you wear a compression stocking or sleeve, or that you elevate the limb.
Surgery may be recommended to remove melanoma anywhere on the body, but procedures performed on particularly sensitive areas of the body may cause more side effects that affect quality of life. Wider excisions, for example, may alter the patient’s appearance and self-confidence. Reconstructive surgery may be an option for some patients, helping to rebuild damaged tissue and restore function. For others, supportive care services, including psychological or group therapy or tissue massage, may help.
Patients receiving immunotherapy may experience side effects ranging from fatigue and nausea to a rash or flu-like symptoms. If you are experiencing severe symptoms, ask your physician whether corticosteroid medications may help or whether your immunotherapy regimen should be adjusted. Oncology rehabilitation techniques, such as massage, reflexology, acupressure and aromatherapy, may help patients cope with pain, numbness, immobility and anxiety. Acupuncture may also help patients manage nausea or pain.
Sun-sensitivity, skin dryness, itchiness and redness are all common side effects of skin cancer treatment. Melanoma patients are also strongly advised to reduce ultraviolet (UV) exposure. When outdoors, always wear UV-protective clothing, including a hat and sunglasses that completely shield your skin from the sun’s rays, which are at their most intense between 10 a.m. and 4 p.m. Continue to wear sunscreen with lip balms with an SPF of at least 30. Talk with your care team about whether certain skin care products or moisturizers may help with itchiness, redness or soreness.
During treatment for melanoma, you may feel uncomfortable after eating. Your care team may include a naturopathic provider and registered dietitianwhowork closely with your oncologists to recommend a balanced diet, supplements and fat-soluble vitamins. These trained clinicians may recommend ways to improve digestion, manage or even prevent nausea, and reduce acid reflux, heartburn, bloating, gas and diarrhea. They may also monitor your supplement and vitamin intake to help prevent drug-herb or drug-nutrient interactions.
Supportive care therapies may help melanoma patients cope with various side effects during and after treatment
Medical science informs all of today’s treatments, which is why clinical trials are so critical to improving the standards of care. Learn about the importance of clinical trials, the rules in place that protect patients, and how patients can get involved.
Our expert, Pamela Crilley, D.O, Chair of the Department of Medical Oncology at Cancer Treatment Centers of America® (CTCA), discusses the risks and benefits of joining a clinical trial and shares why these studies add value.
Because every clinical trial is different, the criteria for selecting qualified patients vary from trial to trial. At Cancer Treatment Centers of America®, your care team will work with you to determine if you qualify for a clinical trial, and if so will walk you through each step.
The field of medicine is constantly evolving, with today’s research informing much of what tomorrow’s treatments may offer patients. For some patients who have exhausted standard treatment options, clinical trials may offer access to treatments that may not have otherwise been considered. Before joining a clinical trial, there are a number of things you should consider.
Clinical trials examine the safety and efficacy of using existing treatments in new ways or developing new drugs or devices that have not yet been fully tested. When considering a clinical trial, it’s important to ask your doctor which studies are available, which may be appropriate options for you, and how you can get as much information as possible about the study you are considering. Ask your doctor to help connect you with the researchers conducting the clinical trial, so you can address concerns and questions you might have.
Write down any questions you may have for your doctor and the research team. You may want to know why the specific approach is being studied and how it may benefit you. You may also want to ask about other relevant studies that have been conducted leading up to this particular trial, and how the treatment being studied differs from the current standard of care. Don’t be shy about asking any questions you may have, or raising concerns that occur to you along the way.
If you are interested in a clinical trial, the research team will ask a number of questions to determine whether you are eligible. Eligibility criteria vary for each clinical trial. Factors such as the type and stage of your cancer, as well as your age, sex, other existing medical conditions, and treatments you have received may be considered when determining eligibility.
Before agreeing to participate in a clinical trial, it’s important to talk with your doctor and the research team about the information they will need to know to determine whether you are eligible. The qualification process may include frequent site visits, which require travel, lab tests, blood work and other procedures that may take up a great deal of your time. One advantage to joining a clinical trial is that patients typically receive hands-on medical care throughout the study. Still, learning ahead of time how much commitment may be involved often helps patients decide whether they are comfortable with participating.
While clinical trials sometimes offer patients access to treatments that may not otherwise have been available to them, it’s important that each patient consider the risks involved, and weigh them against the potential benefits. Ask your doctor and the research team, for example, whether the drug being studied may cause severe side effects, or whether the procedure under investigation causes pain or other complications.
Informed consent is an important part of every clinical trial. It requires that you and your doctor discuss at length the risks and benefits of joining the study, that you have had an opportunity to ask questions and get them answered to your satisfaction, that you have discussed and reviewed a care plan, and that you make a decision you feel is in your best interest. Even if you enroll in a trial and decide at any point along the way that you are no longer interested in continuing, it is also within your rights to stop participating at any time.
If You’re Considering a Clinical Trial, What Questions Should You Ask Your Doctor?
A colorectal cancer diagnosis can be scary for both patients and their families because it raises questions and uncertainty—from how to cope with the condition to learning about treatment options and making a plan for recovery and the road ahead.
Colorectal cancer is a disease that forms in the tissues of the colon and/or rectum, both of which are located in the lower part of the gastrointestinal tract. Colon cancer and rectal cancer are often grouped together because they share many characteristics, symptoms and treatment options. And because the colon and rectum are located so closely together, and play key roles in the body’s digestive system, colorectal cancer’s symptoms and treatments often impact how patients process food and waste.
Colorectal cancer is the third most commonly diagnosed non-skin cancer in the United States, affecting men and women equally. In 2017, U.S. doctors diagnosed an estimated 95,520 new cases of colon cancer and 39,910 cases of rectal cancer. The disease is rising among young people in their 20s and 30s, with low-fiber diets and unhealthy eating overall, excess body weight, lack of physical activity, alcohol consumption and cigarette smoking possibly contributing to this increase, research suggests. Approximately one in 22 men and one in 24 women will be diagnosed with colorectal cancer in their lifetimes. Today, nearly 750,000 men and women each are now cancer-free or are living with colorectal cancer, thanks in part to early detection and more targeted treatments.
Like other illnesses, colorectal cancer risk increases with age. Family history and lifestyle factors may also influence one’s risk, including:
Research suggests being physically active and following a diet that includes milk and dairy may reduce the risk for colorectal cancer.
Understanding colorectal cancer and the treatment options available starts with understanding how the disease is diagnosed and staged. Staging helps physicians create a map of where the cancer is located in the body and how it’s interacting with surrounding tissues, which helps determine an appropriate course of treatment.
Like other cancers, colorectal cancer is diagnosed based on the stage of the disease, indicating a tumor in its earlier stages and IV indicating an advanced tumor. Using imaging technology, biopsies and other advanced diagnostics, physicians determine whether the tumor is localized, regional or metastatic.
Treatments range from surgically removing the primary tumor if the cancer is localized, to more extensive treatments involving chemotherapy and radiation therapy for regional or metastatic cancers.
Surgery is often the first-line treatment. Some early-stage cancers may be treated with minimally invasive techniques, such as a local excision, which uses a transanal endoscope or a flexible tube to access the colon and remove the cancer and surrounding tissue. Another option is a colectomy, in which part or all of the colon is surgically removed along with nearby lymph nodes. In these cases, a colostomy may be required. A total colectomy is less common and may be recommended for patients with complicating factors, such as inflammatory bowel disease or polyps, which are growths in the colon that may or not be cancerous. Or surgery may involve a protectomy, in which the cancerous portion of the rectum is removed.
After surgery, patients may require a colostomy or ilestomy to assist with the removal of waste. The type of procedure offered depends on where the tumor is located. For example, an ilestomy is an opening at the base of the ileum, the lowest part of the small intestine, and is often recommended for patients with histories of ulcerative colitis, polyps or cancer-related complications.
For patients who may not be able to tolerate surgery, radiation therapy is one approach to shrink tumors and kill cancer cells. It may also be used before or after surgery, and in combination with chemotherapy. Radiation therapy delivered before surgery may help shrink tumors making them easier to remove. Radiation therapy may also be delivered after surgery to destroy remaining cancer cells.
Chemotherapy drugs are given in pill or intravenous form. The treatment may be recommended before or after surgery, and it may be delivered regionally to the tumor site, in an effort to spare healthy tissue, or it may be given systemically if the cancer has spread. Chemotherapy that is administered in combination with surgery is designed to shrink the tumor, either before the surgical procedure to allow the tumor to be removed more easily, or afterwards to kill remaining cancer cells in the body.
Medical oncologists have added monoclonal antibodies to their arsenal of colorectal cancer treatments. These treatments are designed to work by directly interfering with the growth of tumors. Some targeted therapies are designed to prevent tumors from developing new blood vessels, while others bind to colorectal cancer cells and disrupt cell signaling, which in turn, limits growth.
Fighting cancer often takes a physical and emotional toll on colorectal cancer patients. That’s why a growing number of medical oncologists recommend an integrative approach that focuses on the mind, body and spirit, to help patients manage pain, stress, appetite loss, lack of stamina, as well as relationship challenges that arise during cancer treatment and recovery. Evidence-informed supportive therapies that include a range of non-invasive and rehabilitative practices may help patients anticipate and reduce the side effects of cancer treatment with nutritional guidance, naturopathic support, chiropractic care, pain management or spiritual support.
Integrative therapies may also include oncology rehabilitation techniques, such as massage, reflexology, aromatherapy or acupuncture, to help improve patients’ quality of life. Many patients also turn to support groups, counseling and other therapies.
To provide patients and their families with a more in-depth understanding of how skin cancer and melanoma are treated today, we spoke with Laura Farrington, DO, Medical Oncologist at Cancer Treatment Centers of America® (CTCA) in suburban Chicago. She shared with us the differences between treating common types of skin cancers, such as basal or squamous cell cancers, versus more invasive types, such as melanoma. We also asked her about new and evolving treatments that are now being used for more advanced melanomas, and the promise of immunotherapy.
Dr. Farrington: Skin cancer is the single most common form of cancer. The most common forms of skin cancer that we see are squamous cell carcinomas, basal cell carcinomas. Sometimes, you can see or feel something is wrong; other times, you can’t, especially if the cancer has grown below the epidermis. Some skin cancers may spread to areas of the body that make it impossible to be seen at all, places like your lungs, your liver, your bones or to unexpected places like your eyes. The only way to know for sure is to get regular skin check-ups by a professional who knows how to distinguish a mole from something more serious.
Dr. Farrington: Dermatologists and physicians look for particular features in a skin lesion, or criteria that we refer to as the ABCs of skin cancer, with each letter representing a particular feature that could signal a problem. When it comes to melanoma, the most threatening form of skin cancer, here’s what we look for:
Dr. Farrington: The first step in treating skin cancer, if it is a localized skin cancer, is to excise it, or surgically remove the tumor. For some people, that's as easy as a simple skin excision. The type of skin cancer determines the type of treatment. Common skin cancers, such as basal cell or squamous cell cancers, are less likely to spread elsewhere on the body, which means they’ve remained localized, and this makes it easier for physicians to treat. Basal cell carcinomas, for example, can be removed in an outpatient setting, right in the doctor’s office, with a local anesthetic. However, if the tumor is on the larger end of the spectrum or if it has spread to local lymph nodes, it will need to be taken care of by a cancer surgeon rather than just a dermatologist.
Dr. Farrington: Melanomas are more likely to spread elsewhere, perhaps even early on as the disease progresses, and require the expertise of cancer surgeons to surgically remove the melanoma and possibly nearby lymph nodes. A lymph node biopsy may be needed at the time of the surgery to see if the melanoma has spread to the lymph nodes. After surgery, melanoma patients, particularly those who have had lymph nodes removed, may require additional therapies such as chemotherapy, immunotherapy or radiation therapy. The most likely place for melanoma to spread initially is to a local lymph node. Once it spreads there, it tends to get into the bloodstream and can spread just about anywhere in the body. Melanoma spreads to the brain more than any other cancer. Because melanoma is more likely than other skin cancer to spread, we have to carefully monitor it even after we remove the primary tumor.
Dr. Farrington: Staging tells us how rapidly a melanoma is moving through the body.
When surgically removing a melanoma, physicians need to have wide surgical margins, so this is something that needs to be done by a cancer surgeon; it is not something that most dermatologists can do in their offices. Wide surgical margins may be needed because, when melanoma spreads from the primary tumor, the skin surrounding the melanoma can potentially have deposits of microscopic cells within the lymphatic system of the skin. When a surgeon removes the melanoma, he or she will remove additional skin to try to ensure that no potential microscopic deposits are left. For example, if a melanoma is up to two millimeters thick, a margin of one to two centimeters is removed. If a melanoma is more than two millimeters thick, a margin of at least two centimeters is removed.
After surgery, more complicated cases of melanoma, such as ocular melanoma in the eye, may require immunotherapy, chemotherapy or radiation therapy. One possible radiation option may be stereotactic radiosurgery, which actually isn’t surgery in the traditional sense. With this procedure, the radiation oncologist pinpoints high doses of radiation for short periods of time, beaming them right at a nodule or aggregation of cells. This allows the oncologist to be precise in zeroing in on the tumor site. Another non-surgical option recommended to some melanoma patients is targeted drug therapy, such as BRAF inhibitors, which work by zeroing in on the BRAF gene, a key feature in about half of all melanomas.
Dr. Farrington: Whenever we talk about any solid cancer being stage IV, it is unlikely to go away completely or stay away forever. However, with all the new melanoma treatments that have come about in the last decade, overall survival rates for the disease have gotten significantly better. Newer targeted therapies and immunotherapies have played a role in increased survival rates. Immunotherapy is an exciting area of cancer treatment because it stimulates the body’s own immune system to attack cancer. Multiple immunotherapy medications called checkpoint inhibitors have been approved by the U.S. Food and Drug Administration for treating melanomas. I think five years down the line, we may be talking about newer and better therapies and the hopes to live even longer.
Medicine wouldn’t be what it is today without clinical trials, which form the foundation of medical research. The goal of clinical trials is to test the safety and effectiveness of a new treatment approach or to determine whether existing treatments may be used in new ways. Cancer patients often participate in clinical trials to gain access to treatments that may have otherwise been unavailable to them. Their participation is essential in helping researchers to measure whether a treatment is safe for patients, to better understand a treatment’s side effects, and to advance the understanding of a particular disease.
Clinical trials are conducted in phases, with each building on the findings from the previous phase.
Knowing which clinical trial may be a good fit for you or a loved one can be overwhelming, with so many studies underway across the country. Various online tools are available to help patients make informed decisions, including databases of clinical trials that patients can search by cancer type, hospital name or clinical trial name. A number of these trials are exploring emerging and potentially breakthrough therapeutics that may offer cancer patients—particularly those with advanced cancer or who no longer respond to standard treatments—improved outcomes and quality of life.
All clinical trials have inclusion and exclusion criteria that limit the studies to relevant, qualified patients. Patients with a relevant type of cancer may be included or excluded from a trial based on various factors, including:
Controlling eligibility is important because it reduces bias in research findings, giving investigators a clearer understanding of how a drug works.
Patient safety is an important component of clinical trials. To ensure protocols and regulations are followed by all those involved, all studies must meet approval from an Institutional Review Board (IRB), an independent committee of professionals, such as doctors, nurses and lawyers.
Clinical trials are typically led by a primary investigator, who oversees all aspects of the trial. They may also include a secondary investigator or co-investigator who is supervised by the primary investigator and is able to make key decisions, as well as a research coordinator who works directly with patients and answers their questions. Before patients agree to participate, the clinical trial team must discuss with them:
Deciding to participate in a clinical trial isn’t always an easy decision. Significant time commitments may be required, or the study may require that patients and their families travel for various reasons, such as for treatment visits, bloodwork, completing questionnaires and follow-ups. Patients may also have to follow specific home care requirements.
Before considering a trial, make sure you ask the research coordinator or another clinical trial team member to clearly explain the possible risks and benefits. Deciding whether to participate in a clinical trial is a personal decision, made by patients and their doctors, and arming yourself with all the facts will help you make an informed decision about whether a particular trial is right for you.
Clinical trials are foundational to the future of medicine, bringing breakthrough treatments from the laboratory to patients, many of whom have complex, life-threatening conditions. For those interested in participating in a clinical trial, it can be overwhelming determining which study is the ideal fit for their needs. We spoke with Pamela Crilley, DO, Medical Oncologist and Chair of Medical Oncology at Cancer Treatment Centers of America® (CTCA) in Philadelphia, about the purpose of cancer clinical trials and how patients can learn more about these treatment opportunities.
Dr. Crilley: A clinical trial investigates a new medication or a systemic agent or device to see whether it would be beneficial to patients, and if we can improve the standard of care. We have clinical trials for patients with cancer at all stages. We investigate the treatment’s efficacy, safety and potential side effects, which are all monitored closely.
A clinical trial can come from several avenues: It can be a trial initiated by a physician-investigator, or it can come through the National Cancer Institute. Oftentimes, you can find clinical trials on clinicaltrials.gov, the government website that details the studies currently available to patients around the United States.
It's important to realize that many of the advances we have in oncology today are thanks to what we learned from earlier clinical trials. For example, the use of adjuvant chemotherapy or chemotherapy for women with breast cancer where a patient doesn’t have a systemic disease can show an improved outcome. That was something we learned from conducting clinical trials on patients, and now it's the standard of care.
Dr. Crilley: No. A patient can participate in clinical trials at different stages of their cancer, but when depends on the study. Some trials are for more advanced disease, while some involve studies on cancers in earlier stages. There are also trials that look at quality of life or other parameters, so trials are not always about treatments. There are many different goals for clinical trials, and patients should look to see which may offer new opportunities for them.
Dr. Crilley: I’ll have long and sometimes multiple conversations with patients and their caregivers to ensure that they clearly understand the risks as well as the duration of the study, exactly what their level of involvement would be, and what’s at stake. Patients need to feel comfortable asking questions so that they can make an informed decision, with the help of their physician and their family. A clinical trial presents patients with an opportunity to really benefit their health and well-being, especially for those who haven’t responded to other treatments, so there’s a great deal to take into account before making a decision.
Dr. Crilley: Clinical trials are heavily regulated, and for good reason—to protect patients. The federal government regulates clinical trials for human research, and there are institutional review boards, or IRBs, that review clinical trials before they are activated at different sites. The IRBs also provide periodic monitoring of clinical trials by conducting continuing reviews. Principal investigators, secondary investigators, research coordinators and everyone on the clinical trial team are required to follow rigorous protocols to ensure every rule is followed, and that we make each individual’s personal safety a priority.
Prior to enrolling in a clinical trial, the patient has to go through the process of informed consent. Informed consent is not just signing a document. Italso includes the discussions that the patient has with his physician and research care team to make sure he understands the potential risks and benefits of the trial andknows thathe may withdraw at any time. A patient should never feel pressured to remain in a clinical study.
Dr. Crilley: A principal investigator is the one in charge of the conducted trial. She or he oversees all aspects of the trial. The principal investigator is also responsible for submitting the protocol to the IRB and conducting continued review and reporting any adverse events or unexpected toxicities to the patient during the trial. A sub-investigator or secondary investigator is a physician who works closely with the principal investigator. He or she helps regulate patient consent and the conduct of the trial.
Dr. Crilley: The majority of the time, these medications or drugs are provided by the insurance companies or the sponsor of the trial. Sometimes, that’s not the case, but I would say the overwhelming majority are provided by the sponsor. Right now, there's really an explosion of clinical trials available for patients across the United States, and this happens to be an extremely exciting time for patients, because there are so many opportunities for treatment that we didn't have before.
Patients recently diagnosed with skin cancer—including melanoma, the most aggressive type of skin cancer—may have countless questions about their health, from wanting to better understand their disease and treatment options to how treatments may impact their quality of life. Knowing how to plan for treatment and recovery and how to reduce the risk of recurrence may help patients maintain a sense of control before, during and after treatment.
Skin cancer is categorized by several types, with basal and squamous cell carcinoma among the most common because of the impact of excessive sun exposure. Other types of skin cancer include Merkel cell carcinoma, Kaposi sarcoma, lymphoma of the skin, and melanoma, the rarest but deadliest form of skin cancer.
Melanoma can occur anywhere on the skin, but it is most common on the scalp and face, which are commonly exposed to the sun. But it is important to know that melanoma may also occur on the chest, back and neck, especially in men, as well as in the eyes, a condition called ocular melanoma. In fact, melanoma may appear in a number of places you wouldn’t expect to be exposed to sunlight, such as behind the ears, under the toenails, or around the genitalia.
Melanoma begins in melanocytes, cells found throughout the body that produce a brown pigment called melanin. This pigment is what gives skin its tan color after being exposed to the sun. If melanoma is not detected early, it may spread to other areas of the body more aggressively than other types of skin cancer.
Skin cancer is the most common type of cancer, with more than 3 million Americans diagnosed with the disease each year. Melanoma, meanwhile, accounts for 1 percent of skin cancers, but it is responsible for the vast majority of skin cancer deaths. In 2017, an estimated 52,170 men and 34,940 women will have been diagnosed with melanoma.
Skin cancers may be caused by too much ultraviolet radiation (UV) exposure from the sun or from artificial sources, such as indoor tanning beds or sun lamps. UV light damages skin cells, increasing the risk for skin cancer. Outdoor UV light is stronger the closer you are the equator or if you live in higher altitudes, so it is important to take precautions, such as wearing sunscreen and protective clothing.
Melanoma rates have been on the rise for the last three decades. Experts believe that an increased use of indoor tanning facilities among young women may have contributed to the higher incidence rates. Melanoma is 20 times more common among whites than blacks, with the lifetime risk at about one in 40 for whites versus one in 200 for Hispanics and one in 1,000 for blacks.
Melanoma increases with age. The typical age at diagnosis is 63. But young people are at risk for the disease, too. Before age 50, women face a higher risk, while men have a greater risk after the age of 50.
Like other types of cancers, family history may increase a person’s skin cancer or melanoma risk. People who may be at higher risk include:
Skin cancers, including melanoma, are staged to measure how advanced they are, which helps determine the course of treatment.
Many skin cancers can be removed with minor surgery using local anesthesia, often at a dermatologist’s office. More complex cases, such as melanoma, require the expertise of a medical oncologist. Melanomas that are localized may also be surgically removed, along with surrounding tissue that may have cancer cells in the margins around the tumor.
Depending on the melanoma’s stage, nearby lymph nodes may also require removal and imaging tests performed to determine whether the cancer has spread. In some cases of metastatic melanoma, surgery to remove the tumor may be followed by additional treatments, such as:
Fighting skin cancer may take a physical and emotional toll, especially for patients with melanoma or other types of advanced skin cancer that require surgery and additional treatment. Surgery, chemotherapy, radiation therapy and targeted drugs may cause a number of side effects that leave patients feeling weak, nauseous or in pain, affecting their quality of life, and sometimes, their ability to remain on their treatment regimen. An integrative approach may help patients anticipate and manage the skin cancer-related side effects, so they are better able to maintain their strength and stamina.
Various supportive care therapies, including pain management techniques, acupuncture and chiropractic care, may be used to combat pain, swelling and numbness after surgery. Oncology rehabilitation approaches, such as massage and occupational therapy, may help restore range of motion and function, while naturopathic remedies may help patients with nausea and loss of appetite. Support groups, counseling and other psychosocial therapies may also be an option.
To provide patients and their families with a more in-depth understanding about colorectal cancer, how it’s treated, and what different options are available, we spoke with Arturo Loaiza-Bonilla, M.D., Chief of Medical Oncology and Medical Director of Research at Cancer Treatment Centers of America® (CTCA) in Philadelphia. Dr. Loaiza-Bonilla focuses on gastrointestinal malignancies. We asked him about the kinds of diagnostics patients may require, the latest approaches in treating colorectal cancer, such as surgery and immunotherapy, and the differences between permanent and temporary ostomies, and when an ostomy may be necessary.
Dr. Loaiza-Bonilla: The first thing we do after a diagnosis, which is usually done by biopsy, is to learn the stage, how big the tumor is, how developed it is, where exactly it is growing, how it is affecting surrounding tissue. We need to know where this cancer is located and where it came from. We then do blood work to get readings on what’s going inside the body, such as kidney and liver function, and to look for tumor biomarkers, which cancer patients may have in their bloodstream and that we don’t usually see in healthy patients. Those tumor marker levels may be elevated in some cancer patients, and not in others. We specifically look at CEA levels, or carcinoembryonic antigen levels, so we follow those numbers throughout treatment. After that, we do CT (computerized tomography) scans, which take images of the chest, abdomen and pelvis to determine whether the cancer is confined to where the colonoscopy found that cancer, or whether it exists elsewhere.
Dr. Loaiza-Bonilla: It’s all based on the stage of the tumor, whether it’s stage I, II, III or IV. Stages I and II are the earliest stages, when the tumor is confined to the colon or rectum; in stage III, it has spread to the lymph nodes; and in stage IV, it has traveled to other organs in the body. For stages I and II, surgeons perform an R0 (R-zero) resection, which is a complete removal of the tumor. They also remove “margins,” or small amounts of surrounding tissue, to ensure they have not left cancerous cells behind.
Dr. Loaiza-Bonilla: It gets more complicated with stage III and IV colorectal cancers, and we need as much information as possible about how the cancer is behaving. Surgeons have to look at removing surrounding lymph nodes for stage III, to see whether the cancer has metastasized further. Also, these patients have a higher risk of recurrence, so after surgery, we often have to add treatments, which may include chemotherapy and/or radiation. For some colorectal cancers, we may give chemotherapy or radiation before surgery to shrink the tumor, which is called neo-adjuvant treatment. This helps produce more positive results from surgery and may help reduce the risk of bowel incontinence, because the surgeon won’t need to go as deep and compromise those sphincter muscles because we’ve shrunk the tumor. We refer to that as “colostomy-free outcomes.” With a stage IV, which is metastatic cancer, we need to look at the genetic blueprints of the tumor, find weaknesses where we can attack, and, based on that information, select particular drugs that can zero in on weak spots. That varies patient by patient.
Dr. Loaiza-Bonilla: Usually, radiation therapy is given in combination with chemotherapy (at a lower dose), and we use it to shrink the tumor before surgery (neoadjuvant), or to remove microscopic cancer cells from the surgical site after we remove the tumor. This mostly depends on the location of the tumor. Rectal cancers are ideal candidates because of the anatomical structure of the rectum, which is confined to the pelvis, making it a fixed portion of the bowel that can be targeted with better precision. The colon is always moving within the abdomen because of peristalsis, which is the medical term for bowel movements. This makes radiation very difficult to administer because we cannot predict where or how the colon will move in that moment in time, making it a moving target. However, the rectum is more fixed, making it a better target for radiation. Patients who have to have part of their rectum removed are more likely to need a colostomy or ileostomy to help them manage waste after surgery. We also use radiation therapy to treat single spots of cancer that has spread or metastasized and causing pain, for example in the bones, etc.
Dr. Loaiza-Bonilla: “Ostomy” means having a diversion somewhere in the body, so an ilestomy is performed on the ileum, or small bowel, and a colostomy is performed on the colon. These two procedures have the same purpose, but the location of the tumor determines which ostomy you need to use. As you know, the digestive tract is quite long. The small bowel can be 20 feet long, and consists of the duodenum, jejunum and ileum. The small bowel is connected to the large intestines, or colon, which is about five feet long. We have several sections of colon, which is very large. The colon consists of the cecum, the ascending colon on the right side, the transverse colon, the descending colon on the left side, and the sigmoid colon, which connects to the rectum and anus. If the tumor is close to the ascending colon or if it’s causing obstruction and you need to bypass the whole colon, that’s when you use an ileostomy. If the tumor is located more toward the end of the colon, and you just need to bypass part of the colon to pass waste, then this is when you might need a colostomy.
Dr. Loaiza-Bonilla: Temporary ostomies are recommended when we anticipate that the reasons for the obstruction are something we can reverse, such as when a bypass in the colon is no longer needed. Temporary ostomies depend on the treatment, such as a complete resection of the tumor, so it could take several months. If a patient has cancer in the lymph nodes after the tumor is removed, we have a window of a few weeks after the surgery when chemotherapy is more likely to have positive results. In those cases, we advise patients to have their ostomy reversed after they’ve finished the chemotherapy. After an ostomy is reversed, the healing process takes time before the patient can return to normal bowel function, usually several weeks to a few months. Permanent ostomies are for when we know bowel function will never be restored. For example, if the patient has a low-lying tumor in the rectum, and we have to remove the sphincter to remove the cancer, then we know the patient will need a permanent ostomy.
Dr. Loaiza-Bonilla: Radiation, either with protons or photons, is limited by the dose and the area. It’s a singular treatment limited by the beam of radiation that’s being delivered, so it’s quite targeted to one area. You could not treat colorectal cancer with radiation therapy if it has spread to other areas of the body or into a number of lymph nodes because you would have to pinpoint all of these individual areas with beams of radiation, and that’s not only ineffective but quite toxic. You could use radiation on a patient with metastatic cancer, but you are only delivering radiation to a single site that is symptomatic. You’re not going to radiate multiple sites at multiple times because that would be too much for any one person to endure. With chemotherapy, the goal is to reach multiple sites with a single drug. Not all drugs are the same; they have different features to attack particular weaknesses of a colorectal tumor and have targeting abilities. With chemotherapy, targeted therapy and immunotherapy, we look for the molecular underpinnings of the tumor so we can destroy the tumor’s DNA and stop it from growing.
Dr. Loaiza-Bonilla: The most recent development in colorectal cancer involves exploring micro-satellite instability (MSI) within the tumor, to determine whether the tumors struggle with DNA repair. We use immunotherapy or drugs called immune checkpoint inhibitors for tumors that are MSI-high or mismatch repair deficient, removing the blindfold of the immune system so it can fight cancer on its own. A tumor that is MSI-high has a broken DNA repair system, and produces several abnormal proteins that the immune system can recognize and then attack, so MSI-high tumors tend to be sensitive to immunotherapy. Two immune checkpoint inhibitors approved by the Food and Drug Administration for MSI-tumors are pembrolizumab and nivolumab. They’re very new. We are seeing quite promising results with these agents, which we are combining with chemotherapy and targeted therapies in some cases, leveraging the immune system to attack tumors. It is a very exciting time to be an oncologist and being able to help many patients with these novel therapies.