January 13, 2026 • 24 mins
On this DocTalk episode, we chat with Dr. Steven Wexner, the Physician Executive Director and System Chief of Colorectal Surgery for MedStar Health. Dr. Wexner brings more than 38 years of clinical, academic, and research excellence to MedStar Health. He specializes in surgery for rectal cancer, and patients from around the world seek his expertise.
For an interview with Dr. Steven Wexner, or for more information about this podcast, contact MedStar Georgetown University Hospital Manager Media Relations, Ryan.M.Miller2@Medstar.net.
Learn more about Dr. Wexner.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
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(00:05):
Comprehensive, relevant,and insightful conversations about health
and medicine happen here on MedStarHealth Doc Talk.
Real conversations with physician expertsfrom around the largest healthcare
system in the Maryland DC region.
Welcome to MedStar Health Doc Talk.
I'm Ryan Miller and I'll beyour host for today's episode.
I'm joined by Dr. Steven Wexner at thePhysician Executive Director and System
(00:26):
Chief of ColorectalSurgery for MedStar Health.
Dr. Wexner is based at MedStar GeorgetownUniversity Hospital and brings more
than 38 years of clinical, academic, andresearch excellence to MedStar Health.
He specializes in surgery for rectalcancer and patients from around the world
seek his expertise.
He is known for his innovations andresearch in rectal and colon cancers,
(00:47):
laparoscopic surgery, complexreoperative pelvic surgery,
and inflammatory boweldisease, just to name a few.
Thank you so much for joining ustoday on Mestar Health Doc Talk.
Thank you very much, Ryan. I'mhonored to be here at MedStar Health.
I'm thrilled to bechatting with you today.
It's very important that we get themessage out to our community in the
Maryland,DC region and beyond about
(01:08):
the importance of colorectalcancer, understanding screening,
understanding symptoms,understanding treatment.
We're so glad to have you on ourteam and definitely look forward to
conversations with you on a variety ofthe clinical areas of expertise that you
have. And today we're going to focus inon rectal cancer. Take it from the top.
(01:30):
What would you say somebody with rectalcancer needs to know and what are the
kind of questions they shouldbe asking their provider?
Unfortunately, some people don'tknow they have rectal cancer,
particularly in younger patientswhere somebody might present
to a physician with bleeding or evenignore bleeding and assume that it's
hemorrhoids,or the treating physician treats his
hemorrhoids and doesn't find out there'srectal cancer.
(01:54):
Those patients are somewhat more fortunatein that they have a symptom that at
some point will get investigated.
Others unfortunately haveno symptoms whatsoever,
and it really highlightsthe importance of screening.
Whether the cancer isthe colon or the rectum,
colorectal cancer is virtually the onlycancer that is preventable by removing
the precursor lesion,by removing the polyp that exists
(02:15):
before it becomes a cancer.
There are exceptionsfor genetic syndromes,
but basically polyps can be removedand if all polyps are removed,
cancer won't occur. So asBenjamin Franklin said,
and it's one of my many favorite quotes,an ounce of prevention is worth more than
a pound of cure. Screening colonoscopyis key. In the case of rectal cancer,
(02:38):
it's even easier because you cansometimes feel it with the finger as an
examining physician orperform a sigmoidoscopy,
which is a much more limited examination.
So the first thing to answer your questionthat people with rectal cancer need
to know is they may not knowthey have rectal cancer.
And the screening guidelines havecome down in age and I believe,
(03:00):
in my opinion,they may come down again because more
and more younger people unfortunately arepresenting with rectal cancer.
That's troubling to hear. Some folksshy away from getting a colonoscopy,
but it sounds like for a rectalscreening, it's not as invasive as that.
It doesn't have to be.
The difference is that arectal cancer may be able to be
(03:22):
detected by a fingerexamination by a physician.
A colon cancer won't because it'sbeyond the reach of a finger. However,
a finger only covers the bottom bit ofthe rectum and there's a lot more that
needs to be assessed and it may beassessed by sigmoidoscopy in the office if
appropriate. Having said that,if a patient has a polyp or
unfortunately a cancer in the rectum,then a full colonoscopy done because
(03:45):
there's a high likelihood there may beadditional lesions that need
to be identified and addressed.
As I mentioned at the beginning,you have brought a wealth of experience
here with you to MedStar Health.
How has the diagnosis and treatment ofrectal cancer evolved during your career?
If we look at the two separateareas, diagnosis and treatment,
(04:05):
diagnosis has become routineby colonoscopy and the
advantage of colonoscopyis any precursor lesions,
any precancerous growths can be identifiedand removed and thus not be able to
become cancer. However,there are now more reliable
non-colonoscopy teststhat are advertised
routinely on television.
(04:26):
They don't offer the advantage of directvisualization and they certainly don't
offer the advantage of removingany polyp or biopsying any lesion,
but they're available.
And that's certainly been an evolutionbecause the only test available when I
was in training more than 40years ago was fecal occult blood,
which basically looks for invisibleto the naked eye blood in the stool.
(04:49):
And that test had about a50% rate of missing growth,
so it wasn't terribly reliable. Andthere's also the other direction,
what we call false positive,where patients who would have what was
thought to be blood wasn't blood andundergo a colonoscopy they didn't need.
So these tests are much more specificand sensitive. What's really changed
though isn't so much the diagnosis.
(05:09):
It's what do we do after we diagnose?
And we now get a rectal cancer protocol,pelvic MRI to look at how
deeply the tumor grows,whether or not any lymph glands involved,
whether or not any bloodvessels or nerves are involved,
because all of those factors helpdirect whether the patient would get
chemotherapy and possibly alsoradiation therapy rather than surgery as
(05:32):
an initial maneuver. So the firstthing is we test differently.
We get the MRI,we get a blood test called
carcinoembryonic antigen,and we get a CAT scan
of the chest, abdomen,and pelvis in addition
to a full colonoscopy.
So there's a very proscribed methodand we'll come a little later to the
importance of multidisciplinary care.
The other thing that's changed is thatit used to be the person who met the
(05:57):
patient,often a surgeon just made the decision
what to do. And that decision may haveentailed a colostomy, a
permanent bag. We have far,far fewer permanent colostomies being
done today than were done 40 years agobecause of better surgical technique
and because chemotherapy and radiationtherapy can shrink the tumors
prior to surgery and allow us tomaintain continuity of the intestinal
(06:19):
tract and attach the colon fromabove the area of the tumor down to the
rectum ranus below where the tumor islocated. So we've improved
our methods of treatment,dramatically improved
our methods of treatment.
And as an added bonus from chemotherapyand radiation, we find that anywhere,
depending on the center,30 or 40% of patients have what's called
a complete response where the tumorcompletely disappears and the patient
(06:43):
doesn't undergo surgery at all.
So instead of just shrinking the tumor,we now eradicate the
tumor without surgery,which is a major advance. There was
something championed by a friend of minefrom Sao Paulo, Brazil,
Professor Angelita Habergama,and it's now become an international
standard. It's called wait and watch.
And you continue to screen thepatient without surgery. So many,
(07:06):
many differences. Another one in termsof technique is that when I trained,
surgery is done through big incisionand now it's minimally invasive.
And minimally invasive technique mightbe laparoscopic through punctures,
robotic through punctures.
It might be transanal where the work isdone up through the bottom rather than
down through the belly or a combinationof the bottom and the belly.
(07:26):
And in some circumstances it might evenbe done by a gastroenterologist or a
surgeon in the endoscopy areawith a flexible instrument.
So the depth and breadth of whatwe can offer patients now is
dramatically different than itwas when I started my career.
Which gives more power to the patients.
Absolutely.
It's all about shared decisionmaking. I guess I can touch on it now.
(07:49):
One of the accomplishments of whichI'm most proud in my career is having
been the catalyst for the NationalAccreditation Program for Rectal Cancer.
In Europe, in the1990s and 2000s,
a variety of countries started organizingwhat they call centers of excellence
where rectal cancer was operated on ormanaged in a multidisciplinary team,
(08:13):
limited numbers of centers inScandinavia, UK, and elsewhere.
We operationally, we were justindividually seeing patients,
radiation oncologists,medical oncologists, surgeons,
with leaders from the AmericanSociety of Colorectal Surgeons,
Society for Surgery, the ElementaryTrack, Society for Surgical Oncology,
(08:33):
American Society of ColonelectalSurgeons, I forget which ones I mentioned,
society, American GastrointestinalEdoscopic Surgeons,
American College of Surgeons,Commission on Cancer,
American College of Radiology,College American Pathologists.
I think that's everyone.
We got together. All the leaders. Yeah.
I may have repeated one, but betterto repeat one than leave it out. Sure.
We got together and createdthis multidisciplinary program,
(08:56):
which was approved initially by theCommission on Cancer. At that time,
I was on the accreditation committee in2014 by the time I was ready to present.
And then by the Board of Regents,which I was on the Board of Regents
at the American College of Surgeons.
And that program is now in over120 programs in the Unitited
States.
And what that program consistsof is that every patient with
(09:19):
rectal cancer presenting at any ofthose 120 plus institutions has to be
presented at themultidisciplinary team conference,
which includes medical oncology,radiation oncology, pathology, imaging,
radiology, surgery plus as needed,other specialists, liver surgery,
spine surgery, urology,gynecology, genetics. And that is,
(09:40):
as you said,giving the patient more choice
because before I would see a patient,let's say 20 years ago and I would
say, "Here's what we're going to do,end of story." Now I say
to the patient, "Look,I may be 38 years into this. I probably
treat more rectal cancers than justabout anyone in the country, but I'm
going to defer to the wisdom of the crowd.
(10:01):
And we're going to present theresults of your MRI, your CAT scan,
chest abd and pelvis, your CAblood test, your colonoscopy,
your pathology report at our NationalAccreditation Program for Rectal Cancer
Multidisciplinary Team Conference.
And the consensus of that group willbe communicated to you thereafter.
And the patients are very happy becausethey're getting all of these different
opinions.
Everybody's current in their own fieldand there are new things coming up every
(10:24):
day like immunotherapy, for example,that's applicable in about 7% of patients
with colorectal cancer where the tumorwill disappear without surgery.
So the patient is in the middle of allof this and we all operate together
keeping the patient in the centerof the decision making process.
Thank you for walking us throughthat. That's really wonderful to hear.
Can you break down the differencesbetween rectal cancer and colon cancer?
(10:47):
Does rectal cancer count as colon cancer?
I like some folks tendto get the two confused.
So can you just break downthe differences between those?
It really is a differenceof anatomic location,
which is significant fortreatment options. For example,
a cancer in the colonwon't, in all probability,
result in needing a bag, eithertemporary or certainly not permanent.
(11:10):
A bit of the colon's removed with thelymph glands and it's put back together.
So that the issue of needing toavoid a permanent bag isn't really
a focus.
For the rectal cancer where therectum is sitting in very crowded
real estate territory, shall we say,with the prostate gland or the vagina,
with the bladder, with the sacrum, thebackbone, the sidewalls of the pelvis,
(11:35):
the anal sphincter muscles, major bloodvessels, the urine carrying structures.
So we have to exercise alot more expertise in the
management to avoid a permanent bagand to give the patient good function.
With the colon, that's not the case.
The other difference is how it spreadsthat the colon cancers are pretty
predictable in followingcertain blood vessels,
(11:58):
veins as they spread. Rectal canceroccasionally can spread in different
directions, particularly the cancersvery, very low down in the rectum.
It really is more of atreatment difference. And
there's abouta little more than double the number
of colon cancers as rectal cancers,roughly 150,000 a year and
more or less 50,000 rectal,100,000 colon, give or take.
(12:22):
And that kind of makes sense becausethere's a lot more colon than there is
rectum. The rectum's about seveninches, let's say, six inches,
seven inches, and the colonis a couple of feet long.
Does anal cancer and rectal cancerhave the same approach to treatment?
The treatment approach which we now haveof wait and watch with chemotherapy and
(12:42):
radiation, eradicating thetumor stemmed from anal cancer.
So anal cancer used to betreated by removing the anus
a permanent bag. Andsometime in the 1970s,
a very clever colorectal surgeonin Detroit, Norman Nigro,
came up with a protocol that's noweponymously called the Nigro Protocol,
(13:03):
and that was giving twodifferent chemotherapeutic
And in his first group of patients,he found that when he then went
and removed the anus and rectum,there's no tumor left.
So he stopped doing it and justleft the anus and rectum in.
And that's become the standard ofcare over the next 70 years since
Norman Nigro firststarted working with it.
(13:24):
And the rectal cancer approachthat Angelita Habragama adopted in
Sao Paulo starting in the 90s,late 80s, early 90s, I believe,
was based on anal cancer. But anal canceris fundamentally very different for
multiple reasons. It'sa different tissue type.
Colon cancer arises frompolyps. Anal cancer does not.
(13:45):
Anal cancer does not arrive from polyps.
There is an association of analcancer with human papillomavirus
and just like there's cervicalcancer in women with papillomavirus.
So it needs to be screenedin high risk populations.
And the mainstay oftreatment is eradication with
There's far less oftensurgery being involved and
(14:08):
Colon and rectum are similar exceptthe anatomy and the way they spread,
whereas anal is rather distinct.
When it comes to thesymptoms of rectal cancer,
is there anything we can watch out forand what should we do if we notice them?
Certainly rectal bleedingis first and foremost.
If somebody develops rectal bleeding,they should have it assessed.
(14:28):
If somebody who happens to have afamily history, a parent, a sibling,
a child who's had colorectalcancer or even colorectal polyps,
there's even heightenedawareness, shall we say,
in a lower threshold for evaluation,but really any bleeding should be
assessed and be careful to have a lowthreshold for colonoscopy because
all too often doctors will say, "Oh,it's hemorrhoids, have some fiber,
(14:48):
soak your bottom in a warm tub,you'll be fine." You really do need at
the very least to get an exam with afinger and have a discussion about
the possibility of a colonoscopy.
So bleeding is number one. If a patientwere to get a constant sense of urgency,
like they need to go to the toilet andnothing's happening or a change in bowel
(15:09):
habits, suddenly instead of havingwhatever frequency somebody has,
that changes and becomes more or lessor more difficult to evacuate or the
consistency of the stool changes,any of those things can be
triggers as well. Certainly,and more advanced, unfortunately,
would be unexplained weight loss.
And is there any way to reducethe risk of rectal cancer?
(15:32):
There's a lot of studies looking atthings like vitamin C like aspirin
and things, and there's inconsistentdata for a lot of these areas.
What is known overall and colonand rectum are the same here.
They can be taken together.
Things that are good for your hearttend to be good for your colon.
So a high fiber diet,low amounts of saturated animal
(15:52):
fats would be good. Exercise,drinking plenty of non-alcoholic,
non-caffeinated beverages.
These are all things that would behealthy to maintain bowel habits,
perhaps taking a supplementof psyllium fiber,
which is an insoluble husk offiber that tends to bulk up the
(16:13):
stool might be of some benefit,but unfortunately there's no real
panacea to say we can prevent it.
I wish that there was.
I wish we could put ourselves out ofbusiness and have patients never again get
rectal cancer,but for now we can just live a healthy
lifestyle. Certainly if one has a familyhistory, need to be very vigilant.
Should be screened earlier than protocol?
Exactly. If somebody hasa first degree relative,
(16:36):
they should start screening at least 10years younger than the youngest first
degree relative.
Okay. And what is thestandard age again for our.
Listeners? 45 tends to be therecommendation at present.
It's come down over the years.
Not too long ago was 50, now 45.
And I suspect, as I said earlier,it may well end up being 40 at some
point in the not too distant future.
(16:58):
Just the number of people we're seeingwho tragically come in. And again,
because the symptoms are notlistened to by the provider
or maybe the patientdoesn't push enough either.
And then unfortunately they come inwith more advanced disease when in all
probability it could have been anearlier stage had it been evaluated at
(17:20):
first presentation.
Rectal cancer treatment ofteninvolves surgery to remove the cancer.
How do you know when surgery is required?
What are some of theother treatment methods?
As we were discussinga little bit earlier,
there's a lot of differenttreatment options for surgery now,
and that decision is made by whatI call the wisdom of the crowd,
the consensus of all the people attendingthe National Accreditation Program for
(17:44):
Rectal Cancer MultidisciplinaryTeam Conference,
which every patient is presented.
And I had the privilege ofchairing the NAPRC for the US,
for the American CollegeSurgeons Commission on Cancer
about two months ago,I finally finished chairing it and have
seen it grow from no programs, as I say,to over 120 programs.
(18:06):
So that discussion is made. Now,it would not be the purview of the group
to tell the surgeon exactly what typeof operation or what approach,
but that's something the surgeon talksto the patient about. For example,
a very early rectal cancer,what we would call T1,
meaning it's just limited to theinnermost lining. We might say, "Well,
we can remove this tumor throughyour bottom with a collotoscope.
(18:27):
We can remove it through yourbottom in the operating room,
some specialized equipment,or we can remove the entirety of the
rectum and lymph glands." And then wediscuss the pros and cons of each of
those surgical approaches with the patientand the patient's family and anyone else
the patient would like to engage in theconversation. And arrived at shared
decision making, the patient would say,"Well, something I'd like to
undergo the transanal excision,have it removed from my bottom, or no,
(18:52):
I don't want to risk that theremight be tumor cells lurking.
I'd rather have you remove therectum and the lymph glands and do a
reconstruction.".
In terms of recovery, after someonehas surgery for rectal cancer,
how long would you say they're in thehospital and how quickly will you know
whether or not the surgeryyou performed was successful?
One of the wonderful things aboutminimally invasive surgery is how patient
(19:14):
friendly it is.
And a lot of the advantages of minimallyinvasive surgery are seen early on.
In other words, hospital stays areshorter because there's less pain.
The bowel function returns more quickly.
So patients typically are in thehospital no more than two or three days
unless they have an ileostomy,a temporary bag protecting the joint up.
(19:35):
And that remains one of the issuesof rectal cancer. So on the one hand,
we can shrink the tumor down withchemotherapy and radiation therapy or just
chemotherapy. But on the other hand,that step prior to surgery unfortunately
increases the risk of the joint up nothealing properly and therefore we do make
a temporary bag upstream.
(19:57):
That temporary bag will keep the patientin the hospital longer because they
need to learn how to manageit and that can add to
end up being about five or six days.
So let's say between the two groups,the average might be four
days for patients thesesurgery as we look around the country.
If the surgery is done through the bottom,it may be a daycase outpatient procedure.
(20:21):
Are you involved in any rectal cancerresearch and why are you optimistic about
this field?
I've been involved and continue tobe involved in a lot of rectal cancer
research. I think during the last year,I've probably published
at least 20 studies.
I've done randomized control trialswith different surgical techniques.
(20:41):
I was the lead and senior investigatorfor the trial that looked at the
combination of operating through thebottom and through the belly at the same
time with what's called transanaltotal mesoretical excision.
I believe those two studies next nowthree were published in the last two years
and a lot of other projects underway.
The fundamental threatof all of these studies
(21:03):
is multifold. The common denominatoris improved quality of life.
The common threads are recognizingit occurs in younger patients,
recognizing that we cansafely treat older patients.
Some of the things we've done,finding techniques that are more patient
friendly and just as efficacious orperhaps more efficacious than the
standard of care intervention. Sothese are all things that I'm working
(21:26):
on and I'm thrilled to be at MedStarHealth, Georgetown University,
particularly with thehaving a National Cancer Institute
Center at which I'm working isa tremendous opportunity to
really help advance the science ofcolorectal cancer management.
(21:47):
We are honored to be theonly NCI comprehensive cancer
DMV. Dr. Wexner,why should patients choose MedStar
Health for colorectal surgery?
Great question, Ryan. And I thinkthat there are many reasons for it,
one of which we were just discussing,and that is the NCI designation
plus the Commission on Cancerdesignation, plus two of our
(22:08):
three teaching hospitals,Hospital Center and Franklin Square
are national accreditation programfor rectal cancer accredited institutions.
And hopefully very soon also,because we're working on it now,
we will seek and hopefully get thataccreditation for MedStar Georgetown
(22:30):
University Hospital. So we'll haveit at all three of our centers.
We have a large number of highly skilled,very technically gifted surgeons who
have great judgment and wonderful handsworking at those three
hospitals and at others,but certainly focusing their
efforts at Franklin Square,at Hospital Center and at
Georgetown. But importantly,we don't operate in a vacuum. And again,
(22:53):
I don't mean operate in the terms ofperforming operations so much as go about
our daily lives because we have phenomenalcolleagues at each of those hospitals
in radiation oncology, medical oncology,gastroenterterology, pathology,
imaging, radiology and the like.
So patients come here,it's one stop shopping.
It's not that I have to go see a surgeonhere and then drive across town to see
(23:16):
my radiation oncologist and then gosomewhere else to get my x-rays done and
hope they get sent and track downthe pathology slides because the
gastroenterologist did the colonoscopyat a freestanding ambulatory surgery
center and I can't get the slides. It'sone stop shopping. It's very convenient.
It's shared conversationand very importantly,
it's that group getting togetherand discussing every patient as a
(23:39):
group to ensure that every patientbenefits from the wisdom of the crowd.
Well said.
I've been talking with Dr. StevenWexner at MedStar Georgetown University
Hospital in Washington DC.
Thank you for sharing your expertisewith us today on MedStar HealthDoctor.
Thank you, Ryan. It's beenan enjoyable conversation.
My parting words to the listeningpublic would be take heed,
(24:02):
get screened.
Rectal cancer is in most casespreventable with appropriate
screening.
Look forward to talking toyou again down the road.
Thank you, likewise.
Comprehensive, relevant,and insightful conversations about health
and medicine happen here on MedStarHealth Doc Talk.
Real conversations with physician expertsfrom around the largest healthcare
system in the Maryland DC region.
Welcome to MedStar Health Doc Talk.
I'm Ryan Miller and I'll beyour host for today's episode.
I'm joined by Dr. Steven Wexner at thePhysician Executive Director and System
(00:26):
Chief of ColorectalSurgery for MedStar Health.
Dr. Wexner is based at MedStar GeorgetownUniversity Hospital and brings more
than 38 years of clinical, academic, andresearch excellence to MedStar Health.
He specializes in surgery for rectalcancer and patients from around the world
seek his expertise.
He is known for his innovations andresearch in rectal and colon cancers,
(00:47):
laparoscopic surgery, complexreoperative pelvic surgery,
and inflammatory boweldisease, just to name a few.
Thank you so much for joining ustoday on Mestar Health Doc Talk.
Thank you very much, Ryan. I'mhonored to be here at MedStar Health.
I'm thrilled to bechatting with you today.
It's very important that we get themessage out to our community in the
Maryland,DC region and beyond about
(01:08):
the importance of colorectalcancer, understanding screening,
understanding symptoms,understanding treatment.
We're so glad to have you on ourteam and definitely look forward to
conversations with you on a variety ofthe clinical areas of expertise that you
have. And today we're going to focus inon rectal cancer. Take it from the top.
(01:30):
What would you say somebody with rectalcancer needs to know and what are the
kind of questions they shouldbe asking their provider?
Unfortunately, some people don'tknow they have rectal cancer,
particularly in younger patientswhere somebody might present
to a physician with bleeding or evenignore bleeding and assume that it's
hemorrhoids,or the treating physician treats his
hemorrhoids and doesn't find out there'srectal cancer.
(01:54):
Those patients are somewhat more fortunatein that they have a symptom that at
some point will get investigated.
Others unfortunately haveno symptoms whatsoever,
and it really highlightsthe importance of screening.
Whether the cancer isthe colon or the rectum,
colorectal cancer is virtually the onlycancer that is preventable by removing
the precursor lesion,by removing the polyp that exists
(02:15):
before it becomes a cancer.
There are exceptionsfor genetic syndromes,
but basically polyps can be removedand if all polyps are removed,
cancer won't occur. So asBenjamin Franklin said,
and it's one of my many favorite quotes,an ounce of prevention is worth more than
a pound of cure. Screening colonoscopyis key. In the case of rectal cancer,
(02:38):
it's even easier because you cansometimes feel it with the finger as an
examining physician orperform a sigmoidoscopy,
which is a much more limited examination.
So the first thing to answer your questionthat people with rectal cancer need
to know is they may not knowthey have rectal cancer.
And the screening guidelines havecome down in age and I believe,
(03:00):
in my opinion,they may come down again because more
and more younger people unfortunately arepresenting with rectal cancer.
That's troubling to hear. Some folksshy away from getting a colonoscopy,
but it sounds like for a rectalscreening, it's not as invasive as that.
It doesn't have to be.
The difference is that arectal cancer may be able to be
(03:22):
detected by a fingerexamination by a physician.
A colon cancer won't because it'sbeyond the reach of a finger. However,
a finger only covers the bottom bit ofthe rectum and there's a lot more that
needs to be assessed and it may beassessed by sigmoidoscopy in the office if
appropriate. Having said that,if a patient has a polyp or
unfortunately a cancer in the rectum,then a full colonoscopy done because
(03:45):
there's a high likelihood there may beadditional lesions that need
to be identified and addressed.
As I mentioned at the beginning,you have brought a wealth of experience
here with you to MedStar Health.
How has the diagnosis and treatment ofrectal cancer evolved during your career?
If we look at the two separateareas, diagnosis and treatment,
(04:05):
diagnosis has become routineby colonoscopy and the
advantage of colonoscopyis any precursor lesions,
any precancerous growths can be identifiedand removed and thus not be able to
become cancer. However,there are now more reliable
non-colonoscopy teststhat are advertised
routinely on television.
(04:26):
They don't offer the advantage of directvisualization and they certainly don't
offer the advantage of removingany polyp or biopsying any lesion,
but they're available.
And that's certainly been an evolutionbecause the only test available when I
was in training more than 40years ago was fecal occult blood,
which basically looks for invisibleto the naked eye blood in the stool.
(04:49):
And that test had about a50% rate of missing growth,
so it wasn't terribly reliable. Andthere's also the other direction,
what we call false positive,where patients who would have what was
thought to be blood wasn't blood andundergo a colonoscopy they didn't need.
So these tests are much more specificand sensitive. What's really changed
though isn't so much the diagnosis.
(05:09):
It's what do we do after we diagnose?
And we now get a rectal cancer protocol,pelvic MRI to look at how
deeply the tumor grows,whether or not any lymph glands involved,
whether or not any bloodvessels or nerves are involved,
because all of those factors helpdirect whether the patient would get
chemotherapy and possibly alsoradiation therapy rather than surgery as
(05:32):
an initial maneuver. So the firstthing is we test differently.
We get the MRI,we get a blood test called
carcinoembryonic antigen,and we get a CAT scan
of the chest, abdomen,and pelvis in addition
to a full colonoscopy.
So there's a very proscribed methodand we'll come a little later to the
importance of multidisciplinary care.
The other thing that's changed is thatit used to be the person who met the
(05:57):
patient,often a surgeon just made the decision
what to do. And that decision may haveentailed a colostomy, a
permanent bag. We have far,far fewer permanent colostomies being
done today than were done 40 years agobecause of better surgical technique
and because chemotherapy and radiationtherapy can shrink the tumors
prior to surgery and allow us tomaintain continuity of the intestinal
(06:19):
tract and attach the colon fromabove the area of the tumor down to the
rectum ranus below where the tumor islocated. So we've improved
our methods of treatment,dramatically improved
our methods of treatment.
And as an added bonus from chemotherapyand radiation, we find that anywhere,
depending on the center,30 or 40% of patients have what's called
a complete response where the tumorcompletely disappears and the patient
(06:43):
doesn't undergo surgery at all.
So instead of just shrinking the tumor,we now eradicate the
tumor without surgery,which is a major advance. There was
something championed by a friend of minefrom Sao Paulo, Brazil,
Professor Angelita Habergama,and it's now become an international
standard. It's called wait and watch.
And you continue to screen thepatient without surgery. So many,
(07:06):
many differences. Another one in termsof technique is that when I trained,
surgery is done through big incisionand now it's minimally invasive.
And minimally invasive technique mightbe laparoscopic through punctures,
robotic through punctures.
It might be transanal where the work isdone up through the bottom rather than
down through the belly or a combinationof the bottom and the belly.
(07:26):
And in some circumstances it might evenbe done by a gastroenterologist or a
surgeon in the endoscopy areawith a flexible instrument.
So the depth and breadth of whatwe can offer patients now is
dramatically different than itwas when I started my career.
Which gives more power to the patients.
Absolutely.
It's all about shared decisionmaking. I guess I can touch on it now.
(07:49):
One of the accomplishments of whichI'm most proud in my career is having
been the catalyst for the NationalAccreditation Program for Rectal Cancer.
In Europe, in the1990s and 2000s,
a variety of countries started organizingwhat they call centers of excellence
where rectal cancer was operated on ormanaged in a multidisciplinary team,
(08:13):
limited numbers of centers inScandinavia, UK, and elsewhere.
We operationally, we were justindividually seeing patients,
radiation oncologists,medical oncologists, surgeons,
with leaders from the AmericanSociety of Colorectal Surgeons,
Society for Surgery, the ElementaryTrack, Society for Surgical Oncology,
(08:33):
American Society of ColonelectalSurgeons, I forget which ones I mentioned,
society, American GastrointestinalEdoscopic Surgeons,
American College of Surgeons,Commission on Cancer,
American College of Radiology,College American Pathologists.
I think that's everyone.
We got together. All the leaders. Yeah.
I may have repeated one, but betterto repeat one than leave it out. Sure.
We got together and createdthis multidisciplinary program,
(08:56):
which was approved initially by theCommission on Cancer. At that time,
I was on the accreditation committee in2014 by the time I was ready to present.
And then by the Board of Regents,which I was on the Board of Regents
at the American College of Surgeons.
And that program is now in over120 programs in the Unitited
States.
And what that program consistsof is that every patient with
(09:19):
rectal cancer presenting at any ofthose 120 plus institutions has to be
presented at themultidisciplinary team conference,
which includes medical oncology,radiation oncology, pathology, imaging,
radiology, surgery plus as needed,other specialists, liver surgery,
spine surgery, urology,gynecology, genetics. And that is,
(09:40):
as you said,giving the patient more choice
because before I would see a patient,let's say 20 years ago and I would
say, "Here's what we're going to do,end of story." Now I say
to the patient, "Look,I may be 38 years into this. I probably
treat more rectal cancers than justabout anyone in the country, but I'm
going to defer to the wisdom of the crowd.
(10:01):
And we're going to present theresults of your MRI, your CAT scan,
chest abd and pelvis, your CAblood test, your colonoscopy,
your pathology report at our NationalAccreditation Program for Rectal Cancer
Multidisciplinary Team Conference.
And the consensus of that group willbe communicated to you thereafter.
And the patients are very happy becausethey're getting all of these different
opinions.
Everybody's current in their own fieldand there are new things coming up every
(10:24):
day like immunotherapy, for example,that's applicable in about 7% of patients
with colorectal cancer where the tumorwill disappear without surgery.
So the patient is in the middle of allof this and we all operate together
keeping the patient in the centerof the decision making process.
Thank you for walking us throughthat. That's really wonderful to hear.
Can you break down the differencesbetween rectal cancer and colon cancer?
(10:47):
Does rectal cancer count as colon cancer?
I like some folks tendto get the two confused.
So can you just break downthe differences between those?
It really is a differenceof anatomic location,
which is significant fortreatment options. For example,
a cancer in the colonwon't, in all probability,
result in needing a bag, eithertemporary or certainly not permanent.
(11:10):
A bit of the colon's removed with thelymph glands and it's put back together.
So that the issue of needing toavoid a permanent bag isn't really
a focus.
For the rectal cancer where therectum is sitting in very crowded
real estate territory, shall we say,with the prostate gland or the vagina,
with the bladder, with the sacrum, thebackbone, the sidewalls of the pelvis,
(11:35):
the anal sphincter muscles, major bloodvessels, the urine carrying structures.
So we have to exercise alot more expertise in the
management to avoid a permanent bagand to give the patient good function.
With the colon, that's not the case.
The other difference is how it spreadsthat the colon cancers are pretty
predictable in followingcertain blood vessels,
(11:58):
veins as they spread. Rectal canceroccasionally can spread in different
directions, particularly the cancersvery, very low down in the rectum.
It really is more of atreatment difference. And
there's abouta little more than double the number
of colon cancers as rectal cancers,roughly 150,000 a year and
more or less 50,000 rectal,100,000 colon, give or take.
(12:22):
And that kind of makes sense becausethere's a lot more colon than there is
rectum. The rectum's about seveninches, let's say, six inches,
seven inches, and the colonis a couple of feet long.
Does anal cancer and rectal cancerhave the same approach to treatment?
The treatment approach which we now haveof wait and watch with chemotherapy and
(12:42):
radiation, eradicating thetumor stemmed from anal cancer.
So anal cancer used to betreated by removing the anus
a permanent bag. Andsometime in the 1970s,
a very clever colorectal surgeonin Detroit, Norman Nigro,
came up with a protocol that's noweponymously called the Nigro Protocol,
(13:03):
and that was giving twodifferent chemotherapeutic
And in his first group of patients,he found that when he then went
and removed the anus and rectum,there's no tumor left.
So he stopped doing it and justleft the anus and rectum in.
And that's become the standard ofcare over the next 70 years since
Norman Nigro firststarted working with it.
(13:24):
And the rectal cancer approachthat Angelita Habragama adopted in
Sao Paulo starting in the 90s,late 80s, early 90s, I believe,
was based on anal cancer. But anal canceris fundamentally very different for
multiple reasons. It'sa different tissue type.
Colon cancer arises frompolyps. Anal cancer does not.
(13:45):
Anal cancer does not arrive from polyps.
There is an association of analcancer with human papillomavirus
and just like there's cervicalcancer in women with papillomavirus.
So it needs to be screenedin high risk populations.
And the mainstay oftreatment is eradication with
There's far less oftensurgery being involved and
(14:08):
Colon and rectum are similar exceptthe anatomy and the way they spread,
whereas anal is rather distinct.
When it comes to thesymptoms of rectal cancer,
is there anything we can watch out forand what should we do if we notice them?
Certainly rectal bleedingis first and foremost.
If somebody develops rectal bleeding,they should have it assessed.
(14:28):
If somebody who happens to have afamily history, a parent, a sibling,
a child who's had colorectalcancer or even colorectal polyps,
there's even heightenedawareness, shall we say,
in a lower threshold for evaluation,but really any bleeding should be
assessed and be careful to have a lowthreshold for colonoscopy because
all too often doctors will say, "Oh,it's hemorrhoids, have some fiber,
(14:48):
soak your bottom in a warm tub,you'll be fine." You really do need at
the very least to get an exam with afinger and have a discussion about
the possibility of a colonoscopy.
So bleeding is number one. If a patientwere to get a constant sense of urgency,
like they need to go to the toilet andnothing's happening or a change in bowel
(15:09):
habits, suddenly instead of havingwhatever frequency somebody has,
that changes and becomes more or lessor more difficult to evacuate or the
consistency of the stool changes,any of those things can be
triggers as well. Certainly,and more advanced, unfortunately,
would be unexplained weight loss.
And is there any way to reducethe risk of rectal cancer?
(15:32):
There's a lot of studies looking atthings like vitamin C like aspirin
and things, and there's inconsistentdata for a lot of these areas.
What is known overall and colonand rectum are the same here.
They can be taken together.
Things that are good for your hearttend to be good for your colon.
So a high fiber diet,low amounts of saturated animal
(15:52):
fats would be good. Exercise,drinking plenty of non-alcoholic,
non-caffeinated beverages.
These are all things that would behealthy to maintain bowel habits,
perhaps taking a supplementof psyllium fiber,
which is an insoluble husk offiber that tends to bulk up the
(16:13):
stool might be of some benefit,but unfortunately there's no real
panacea to say we can prevent it.
I wish that there was.
I wish we could put ourselves out ofbusiness and have patients never again get
rectal cancer,but for now we can just live a healthy
lifestyle. Certainly if one has a familyhistory, need to be very vigilant.
Should be screened earlier than protocol?
Exactly. If somebody hasa first degree relative,
(16:36):
they should start screening at least 10years younger than the youngest first
degree relative.
Okay. And what is thestandard age again for our.
Listeners? 45 tends to be therecommendation at present.
It's come down over the years.
Not too long ago was 50, now 45.
And I suspect, as I said earlier,it may well end up being 40 at some
point in the not too distant future.
(16:58):
Just the number of people we're seeingwho tragically come in. And again,
because the symptoms are notlistened to by the provider
or maybe the patientdoesn't push enough either.
And then unfortunately they come inwith more advanced disease when in all
probability it could have been anearlier stage had it been evaluated at
(17:20):
first presentation.
Rectal cancer treatment ofteninvolves surgery to remove the cancer.
How do you know when surgery is required?
What are some of theother treatment methods?
As we were discussinga little bit earlier,
there's a lot of differenttreatment options for surgery now,
and that decision is made by whatI call the wisdom of the crowd,
the consensus of all the people attendingthe National Accreditation Program for
(17:44):
Rectal Cancer MultidisciplinaryTeam Conference,
which every patient is presented.
And I had the privilege ofchairing the NAPRC for the US,
for the American CollegeSurgeons Commission on Cancer
about two months ago,I finally finished chairing it and have
seen it grow from no programs, as I say,to over 120 programs.
(18:06):
So that discussion is made. Now,it would not be the purview of the group
to tell the surgeon exactly what typeof operation or what approach,
but that's something the surgeon talksto the patient about. For example,
a very early rectal cancer,what we would call T1,
meaning it's just limited to theinnermost lining. We might say, "Well,
we can remove this tumor throughyour bottom with a collotoscope.
(18:27):
We can remove it through yourbottom in the operating room,
some specialized equipment,or we can remove the entirety of the
rectum and lymph glands." And then wediscuss the pros and cons of each of
those surgical approaches with the patientand the patient's family and anyone else
the patient would like to engage in theconversation. And arrived at shared
decision making, the patient would say,"Well, something I'd like to
undergo the transanal excision,have it removed from my bottom, or no,
(18:52):
I don't want to risk that theremight be tumor cells lurking.
I'd rather have you remove therectum and the lymph glands and do a
reconstruction.".
In terms of recovery, after someonehas surgery for rectal cancer,
how long would you say they're in thehospital and how quickly will you know
whether or not the surgeryyou performed was successful?
One of the wonderful things aboutminimally invasive surgery is how patient
(19:14):
friendly it is.
And a lot of the advantages of minimallyinvasive surgery are seen early on.
In other words, hospital stays areshorter because there's less pain.
The bowel function returns more quickly.
So patients typically are in thehospital no more than two or three days
unless they have an ileostomy,a temporary bag protecting the joint up.
(19:35):
And that remains one of the issuesof rectal cancer. So on the one hand,
we can shrink the tumor down withchemotherapy and radiation therapy or just
chemotherapy. But on the other hand,that step prior to surgery unfortunately
increases the risk of the joint up nothealing properly and therefore we do make
a temporary bag upstream.
(19:57):
That temporary bag will keep the patientin the hospital longer because they
need to learn how to manageit and that can add to
end up being about five or six days.
So let's say between the two groups,the average might be four
days for patients thesesurgery as we look around the country.
If the surgery is done through the bottom,it may be a daycase outpatient procedure.
(20:21):
Are you involved in any rectal cancerresearch and why are you optimistic about
this field?
I've been involved and continue tobe involved in a lot of rectal cancer
research. I think during the last year,I've probably published
at least 20 studies.
I've done randomized control trialswith different surgical techniques.
(20:41):
I was the lead and senior investigatorfor the trial that looked at the
combination of operating through thebottom and through the belly at the same
time with what's called transanaltotal mesoretical excision.
I believe those two studies next nowthree were published in the last two years
and a lot of other projects underway.
The fundamental threatof all of these studies
(21:03):
is multifold. The common denominatoris improved quality of life.
The common threads are recognizingit occurs in younger patients,
recognizing that we cansafely treat older patients.
Some of the things we've done,finding techniques that are more patient
friendly and just as efficacious orperhaps more efficacious than the
standard of care intervention. Sothese are all things that I'm working
(21:26):
on and I'm thrilled to be at MedStarHealth, Georgetown University,
particularly with thehaving a National Cancer Institute
Center at which I'm working isa tremendous opportunity to
really help advance the science ofcolorectal cancer management.
(21:47):
We are honored to be theonly NCI comprehensive cancer
DMV. Dr. Wexner,why should patients choose MedStar
Health for colorectal surgery?
Great question, Ryan. And I thinkthat there are many reasons for it,
one of which we were just discussing,and that is the NCI designation
plus the Commission on Cancerdesignation, plus two of our
(22:08):
three teaching hospitals,Hospital Center and Franklin Square
are national accreditation programfor rectal cancer accredited institutions.
And hopefully very soon also,because we're working on it now,
we will seek and hopefully get thataccreditation for MedStar Georgetown
(22:30):
University Hospital. So we'll haveit at all three of our centers.
We have a large number of highly skilled,very technically gifted surgeons who
have great judgment and wonderful handsworking at those three
hospitals and at others,but certainly focusing their
efforts at Franklin Square,at Hospital Center and at
Georgetown. But importantly,we don't operate in a vacuum. And again,
(22:53):
I don't mean operate in the terms ofperforming operations so much as go about
our daily lives because we have phenomenalcolleagues at each of those hospitals
in radiation oncology, medical oncology,gastroenterterology, pathology,
imaging, radiology and the like.
So patients come here,it's one stop shopping.
It's not that I have to go see a surgeonhere and then drive across town to see
(23:16):
my radiation oncologist and then gosomewhere else to get my x-rays done and
hope they get sent and track downthe pathology slides because the
gastroenterologist did the colonoscopyat a freestanding ambulatory surgery
center and I can't get the slides. It'sone stop shopping. It's very convenient.
It's shared conversationand very importantly,
it's that group getting togetherand discussing every patient as a
(23:39):
group to ensure that every patientbenefits from the wisdom of the crowd.
Well said.
I've been talking with Dr. StevenWexner at MedStar Georgetown University
Hospital in Washington DC.
Thank you for sharing your expertisewith us today on MedStar HealthDoctor.
Thank you, Ryan. It's beenan enjoyable conversation.
My parting words to the listeningpublic would be take heed,
(24:02):
get screened.
Rectal cancer is in most casespreventable with appropriate
screening.
Look forward to talking toyou again down the road.
Thank you, likewise.
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