Center of Attention

The new Colorectal Center at USC/Norris Comprehensive Cancer Center entwines
the full spectrum of colorectal cancer health professionals and resources into one vital lifeline for parents.
by Alicia Di Rado

At USC/Norris, colorectal cancer patients anxious about treatment can be matched up with an advocate who has gone through it all before. They can rely on frank talk with a physical therapist who helps them recover from surgery. And a monthly support group meeting unites them with others facing the same challenges.

Yet these services provide only a window into the caring team that colon and rectal cancer patients can expect at USC/Norris. Successfully combating cancer and coping with its many lasting effects requires a call to arms that only a full squad of talented professionals from a variety of disciplines can answer.

That is why professionals dedicated to colorectal cancer—patient advocates, oncologists, nurses, surgeons, social workers, nutritionists and counselors, among many others—all have a single place to call home at USC/Norris. That place is the new Colorectal Center, an endeavor that entwines all of the Norris’ colorectal cancer resources into one vital lifeline for patients.

“We want this to be the colon cancer center nationwide,” says Heinz-Josef Lenz, M.D., associate professor of medicine and director of USC/Norris’ gastrointestinal oncology program. “This will set the gold standard for treatment.”

Robert W. Beart Jr., M.D., the Charles and Carolyn Costello Professor of Surgery, likens the approach to that of the Harold E. and Henrietta C. Lee Breast Center at USC/Norris, where everyone important to patient care unites under one banner.

“It’s not that we haven’t had all the elements for this center before, but they haven’t been coordinated in a timely fashion for patients,” explains Beart, who also holds the Audrey Skirball-Kenis Chair for Colorectal Diseases.

And, of course, they aim to bring the once-taboo topic of colon and rectal cancer to the forefront. Their most valuable tool: a cadre of dedicated health professionals.

One place Physicians’ knowledge and judgment, combined with that of fellow professionals, provide a framework for decisions that patients and their caregivers must make during treatment and beyond.

When patients are diagnosed with colon or rectal cancer, their treatment depends on the cancer’s credentials: How big is it? Where is it? Has it spread through the wall of the colon or rectum, and has it metastasized to nearby or far-away organs? Is it slow-growing or aggressive?

Such cancers are most often diagnosed during a colonoscopy, when a surgeon may snip a suspicious polyp and send it to the USC/Norris pathology lab for examination. The pathologist, a physician specially trained to recognize and characterize cancer cells, examines the thinly sliced and dyed tissue sample under a microscope to see if cells are abnormal.

Other physicians known as radiologists also hunt down cancer clues through images of the colon and other parts of the body using barium enemas, ultrasound, computed tomography studies, magnetic resonance imaging and other techniques.
Surgeons such as Beart then remove tumors, check for cancer spread, and reconstruct the bowel so patients retain the highest-possible function.

For many patients, chemotherapy is the next step. Medical oncologists such as Lenz and Syma Iqbal, M.D., assistant professor of medicine, create a sort of genetic fingerprint of the patient’s particular cancer before customizing a plan for administering chemotherapy drugs.

They run a barrage of tests to find genetic markers that can steer them to a menu of anti-cancer drugs with the greatest potential to fight the tumor.

Sometimes they provide chemotherapy before surgery to shrink tumors, making them easier to take out while preserving important tissue. And in the case of rectal cancer, a physician such as Emily L. Militzer, M.D., assistant professor of radiation oncology, may join the team to administer radiation therapy. These high-energy rays can shrink tumors before surgery or kill any tiny deposits of cancerous cells that might remain behind after surgery.

Other treatments are possible too, depending on the cancer’s stage.

If cancer has metastasized to the liver, Rick Selby, M.D., professor of surgery and chief of the division of hepatobiliary and pancreatic surgery, joins the team to remove liver tumors in a follow-up operation. Tumors in the liver can show up as late as five years after the initial colon cancer treatment.

“Probably 5 to 25 percent of patients have these tumors,” Selby says. “We recommend liver resection whenever we can render the patient disease free. We can take out up to 75 percent of the liver.”

With so many physicians, therapists and nurses with differing schedules potentially involved in the treatment of one patient, speedy communication can be complicated. Bringing Colorectal Center team members together in the same place on a regular schedule streamlines that communication—and benefits patients.

“This system is a lot more efficient in terms of decision-making,” Selby says. “There’s a brainstorming effort. We can all sit down and ask questions: Should a patient have chemotherapy before or after surgery? Should they be in a clinical trial?

“This way, we can come to a conclusion by consensus, which ultimately helps the patient.”

Lenz says it offers patients convenience, a key point particularly for those who travel long distances. The USC/Norris colorectal cancer program is so widely recognized that patients come not only from all over the U.S. but from Asia, South America and Europe for treatment. USC physicians see more colorectal cancer patients than any other treatment center in California.

“When patients come from far away, they want a comprehensive workup in one place, at one time,” Lenz says. “They can schedule tests and appointments with different people for the same day, and don’t have to keep coming back.”

Key players
Nurses form the front line of the Colorectal Center. When patients get a fever, they call a nurse. When they are having trouble with a colostomy after surgery, they call a nurse.
And when they are frustrated or scared, they call a nurse.

Yolee Casagrande, R.N., is clinical nurse coordinator at the center. She can flip through her memory like a Rolodex, remembering seemingly every patient.

Casagrande matches worried patients with other survivors for support. “Let’s say there’s a 53-year-old man who is going to undergo surgery,” she says. “I try to match him with someone he can relate to, someone who has been there before and can tell him first-hand what to expect.

“Sometimes patients tell each other things and feel a bond that they feel with no one else.”

This sensitivity makes its way to patient care, and it matters. “Psychosocial issues are very important to our patients,” Beart says. “It’s not a matter of getting through surgery or chemotherapy and that’s it, they’re done. These patients have to deal with having a chronic disease.

“Nurses are involved with patients even before surgery. Nurses become the floor on which this whole center stands.”

Casagrande is overseeing the creation of educational materials for all patients. The center will have an office dedicated to patient education, as well as a Web site.

“Every patient will receive an individualized manual that will address issues specific to them,” Casagrande explains. “For example, it would not make sense to include information about radiation therapy for a patient getting treatment for colon cancer, since radiation is used for rectal cancer patients.

“We want to include information that is customized exclusively for each patient.”

Lenz is enthusiastic about the materials’ modular format. Educators may insert modules in each patient’s manual as needed, and everyone will get a sheet with answers to frequently asked questions and a listing of emergency phone numbers.

“It’s been shown that patients miss 85 percent of what they are told during doctors’ visits,” Beart says, “so this will be a great reference.”

Team togetherness
“Each person in this program has an active role in helping the patient, right from the get-go,” says Beart. Each performs invaluable services that better the Colorectal Center, he notes, listing the team members: social workers, stoma therapists, nutritionists, radiation therapists, genetic counselors, physical therapists and their assistants.

Social workers, for one, help with depression and quality-of-life issues. Even after treatment, many patients have lasting problems with parts of life that might ordinarily be taken for granted, such as sexual relationships. Social workers listen and suggest ways to cope.

They also offer a support group for colorectal cancer patients once a month, Casagrande notes. Patients’ caregivers and family members are welcome, too. And a special luncheon each March reunites patients with friends made during treatment.

In addition, a new patient liaison and coordinator serves as an advocate for patients. A former colon cancer patient, the coordinator answers patients’ questions, shepherds patients from physician to physician and wards off possible paperwork tangles.

A nutritionist guides patients on dietary recommendations, following proven research findings on foods and nutrients needed for overall health. Physical therapist Julie Reynolds, Ph.D., also helps. She provides therapy to battle incontinence, especially among rectal cancer patients, who are instructed on focused exercises to strengthen sphincter muscles.

And when patients might have an inherited, genetic basis for their cancer, genetic counselor Monica Alvarado, M.S., C.G.C., can work with patients’ family members to assess their cancer risk.

“We envision family screenings and chemoprevention protocols,” says Lenz. When family members are seen to be at high risk for colon cancer, they may be put on a more aggressive screening schedule to detect cancer early.

Lenz notes that identifying families with an inherited cancer risk also fits into the work of USC/Norris researcher Robert Haile, Dr.P.H., who directs a growing national registry of families at high risk for developing colorectal cancer (see “All in the Family,” page 8). The idea: to find new candidate genes linked to colorectal cancer risk.

Haile is not only looking at the genetic causes of cancer, but also environmental ones—as well as how to stop cancer from happening in the first place. For example, in a recent study, he and his colleagues found that taking aspirin can reduce the risk of colon cancer in those at high risk for the disease. Calcium, folic acid and substances in broccoli, cabbage and other cruciferous vegetables are just a few of the other compounds under study.

In the future, patients and families may be able to access trials involving such substances, Lenz says. Patients may also benefit from USC/Norris research on new treatments.

“The better we work together clinically, the better we can get research advances to patients,” he adds.

Beart, meanwhile, is focused on providing the best possible day-to-day management of patients, using advanced therapies. His ultimate measure of the center team’s success lies in the patients themselves.

“Nationally, there’s a tremendous body of data that says that colon cancer treatment by physicians specializing in the disease means better outcomes than does treatment from general surgeons. But we aren’t resting on that laurel,” Beart says. “We don’t just want to address patients’ cure rates, but their overall well-being—and that of their family members.”

For more information about the Colorectal Center or The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273).