Colorectal Cancer - Pathologists' Key Role in Improving Patient Care

• More information about the CAP Cancer Protocols
• For questions, please email us at CancerProtocols@cap.org.

Julie McDowell:

March is Colorectal Cancer Awareness Month. In 2022, the American Cancer Society's Cancer Statistics Center estimates that more than 150,000 patients will be diagnosed with colorectal cancer in the United States, with more than 52,000 dying of the disease.

Early detection through prevention and screening is proven to dramatically reduce fatalities from this cancer, especially among young adults. The CAP cancer protocols help ensure that all pathology reports contain necessary data elements to improve patient care.

In this CAPcast discussion, pathologist Dr. Lawrence Burgart and Dr. William Chopp, members of the CAP Cancer Committee, are joined by Dr. Manish Sharma, an oncologist based in Grand Rapids, Michigan, and the Associated Director of Clinicals Research at Start Midwest. They'll discuss the role that CAP colorectal cancer protocols have in diagnosing and treating patients with this condition. Dr. Sharma, can you start our conversation off by talking about some recent trends in diagnosing colorectal cancer?

Dr. Manish Sharma:

Sure. Probably the most important trend is that we're in general diagnosing colorectal cancer at earlier ages and at earlier stages of the disease, and that has a lot to do with screening. So I'm sure as much of our audience is aware, the guidance was changed recently and now it's being recommended that patients get their first colorectal cancer screening colonoscopy done at age 45. So hopefully we'll be catching these cancers earlier, both earlier in life as well as at earlier stages when it's more treatable and more curable.

Julie McDowell:

So Dr. Burgart, the CAP has three different protocols for colorectal cancers. What are some of the critical elements a pathologist or trainee should keep in mind when using each of the protocols?

Dr. Lawrence Burgart:

Yeah. These three protocols are very different from each other and have very different intent and specific content. So the one people are most familiar with, no doubt, is the resection protocol, which covers the typical right hemicolectomy, proctocolectomy, any segmental resection, and even the transanal excisions. And that contains all the staging information for a typically excised colon cancer.

The protocol that people probably think less about is called the biopsy protocol, but it's a little bit of a misnomer. Once you open up the protocol, you really see that it's for polypectomy specimens. And so when a polyp is removed and has an often unexpected malignancy within that polyp, this biopsy protocol really helps to get all of the factors that are needed, not only to stage it but to make sure the colorectal surgeon has the right information to know what to do next, if the patient needs additional surgery or not.

And then the third protocol, equally important but very different, is the biomarkers protocol, which really helps get all of the reported elements of the ancillary testing, such as the DNA mismatch repair or HER2 testing into the report as well. So those three protocols are very different, complimentary and extremely helpful to getting all of the pertinent information into the report.

Julie McDowell:

Now, Dr. Chopp, have there been any recent updates to the protocols or changes to the histologic types that users should keep in mind?

Dr. William Chopp:

Nothing per se right now for the histologic types, but with that question, kind want to elucidate. These protocols are always updated every couple of years, and we always try to look at the latest data. When we get asked for different biomarkers, HER2 [inaudible] has been a specific example of that. In colon cancer, we're being asked to do that in metastatic disease. And with Andrew Bellizzi's help in University of Iowa, we had a lot of good information about how to apply that. As we all know right now, there's a lot of different methodologies that people can use. And in the biomarker template, we've tried to help educate people about some of the possibilities that they can use when trying to navigate that rough water.

Julie McDowell:

So Dr. Burgart and Dr. Chopp, I'd like to hear from both of you about the importance for pathologists to use standardized synoptic reporting, like the cancer protocols, and what impact it can have on downstream data use for public health initiatives or cancer registries. Dr. Burgart, can we start with you?

Dr. Lawrence Burgart:

Yes. Thanks, Julie. The example of airline pilots using list is cliche now, but it's such an important example because of its critical nature. And these checklists, these protocols really allow pathologists in a busy practice with a lot of diverse specimens to make sure that all of the elements that are needed for treatment are included. And that carries downstream to allow data gathering agencies, cancer registrars to collect that data in a uniform way.

And for instance, with the cancer registry, it really allows us to judge the quality of our practice. And of course, it's a much bigger picture item to think about the public health decisions that are made later, but probably equally important. In our own practice though, we just use these uniformly collected data to judge both our clinical quality and our pathology quality in dealing with these specimens.

Julie McDowell:

Dr. Chopp, what's your perspective?

Dr. William Chopp:

As Larry was talking, or Dr. Burgart was talking here, I kind of smiled back to my residency. I remember when we didn't have these cancer checklist templates and I would try to put all of this information in there. And sometimes missing quite a few things in these reports, and then getting called a couple days later about, "Hey, how many lymph nodes were positive," or, "what about that distal margin? You made no comment to that." And as Larry said, it may be cliche a little bit, but we forget about a lot of these things if we don't have it in front of our face. And this helps us to do it in a systematic manner so we don't forget. So if someone goes from Michigan or travels to California, those reports should have the same information and those oncologists can act in a similar manner.

Julie McDowell:

So Dr. Sharma, can you talk about the impact of reporting generated from the cancer protocols on your treatment decisions?

Dr. Manish Sharma:

Yeah, it's absolutely critical that we get the information from these protocols when we're talking with patients and making recommendations regarding treatment as their oncologists. A good example is a stage two colon cancer where mismatch repair testing is very critical in deciding whether or not to give adjuvant chemotherapy. Even in the metastatic disease setting where patients have stage four disease, we're using the information from these reports to guide treatment decisions. We treat mismatch repair deficient colorectal cancers differently than mismatch repair proficient colorectal cancers. We also use the HER2 testing results to guide treatment decisions. And there are other results as well that have to do with the molecular analysis on these tumors. That includes things like KRAS and NRAS and BRAF testing. These are genes that can have mutations in them in patients with colorectal cancer. So I think the more information that we can get on these reports that is covering all the necessary details is very critical for us in making these treatment decisions for patients.

Julie McDowell:

Any final thoughts before we conclude?

Dr. Lawrence Burgart:

I would like to highlight and emphasize something that Dr. Chopp said about these protocols being living documents. Although the CAP Cancer Committee tries to be judicious in putting out new versions of these protocols, we are constantly vetting and updating based on the data that's coming out. I think it was important that Dr. Chopp mentioned that, and it's a subspecialty group on the CAP Committee with both academic and community practice pathologists working on these protocols to try to make sure that we get up-to-date information to our oncologists, colleagues like Dr. Sharma, and get the patients the best treatment.

Julie McDowell:

Well thank you all for this discussion. For more information on CAP cancer protocols, please visit cap.org and click on protocols and guidelines at the top of the homepage.

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