A conversation with Cary B. Aarons, MD, Vice Chair of Education, Program Director of the General Surgery Residency Program, and Interim Chief of the Division of Colorectal Surgery, about the intersection of research, education, and awareness of colorectal cancer and inflammatory bowel disease (IBD).
Exploring the Unknowns of Colorectal Cancer
Let’s start with a pressing topic: early-onset colorectal cancer or the rise of colorectal cancer in younger people. Are there any leads behind this mystery?
It’s increasing at an alarming rate, and the etiology and causes are largely unknown. I think the prevailing thought initially was that this has to be genetic. These are young patients; there must be some genetic reason why younger patients under 50 years old would get this. Certainly, some syndromes have a higher prevalence of colon cancer. Still, a lot of the early onset colorectal cancer that we're seeing are actually sporadic cancers, meaning that they don't have a genetic cause.
So, there must be multifactorial underlying reasons, which probably stem from modifiable risk factors like diet and physical activity. And to some degree, environmental causes like smoking and alcohol could also contribute to that, as could the gut microbiome, which is an evolving field itself.
What kind of research is happening at Columbia to explore these cancer unknowns?
The work that Beatrice Dionigi [colorectal surgeon], Joel Gabre, a GI doctor, and medical oncologist Yoanna Pumpalova are doing in biobanking and organoid research is starting to help us clarify this more.
They're looking at both early-onset tissue and early-onset colon cancer, as well as tissue from older patients, to see if there is a difference at the cellular level that we haven't identified. And I think that's really exciting stuff. I mean, the research itself is really groundbreaking.
How do you see that impact affecting patient care?
A model that we're piloting here is similar to other cancer pathologies. The concept involves a multidisciplinary clinic and coordinated care of cancer patients. It's something that's certainly well established at Columbia in pancreatic cancer, breast cancer, and other cancers as well. A lot of the colorectal care is already very coordinated. We have multidisciplinary tumor boards, but I think we can take it a step further by coordinating care in a very integrated way across the health system.
Will you explain what coordinated care across the health system means?
It's a matter of shining a brighter light on the stuff that we do every day and being more intentional about it. These include co-locating clinics, having all the doctors in one place with one appointment, and seeing providers not only in colorectal surgery and oncology but also getting our radiation oncology partners involved.
There are many tangible benefits to this approach. The literature shows that coordinated care improves adherence to clinical guidelines. I think it certainly lends the opportunity for improvement in clinical decision-making. From a scientific discovery standpoint, there's an opportunity to really improve enrollment and recruitment in clinical trials.
It sounds like clinical education and patient education really feed into each other.
I think you're exactly right, especially with cancers. Whenever a patient has a new diagnosis, things start happening so quickly. It’s hard to absorb all the information. Coordinated care ensures the support of the treatment team and a greater opportunity for the family to be involved and get educated. If someone has multiple visits with different providers for the same reason, they may or may not have the same support that they would in one visit. And if you don’t know if your doctors are actually talking to each other, it’s very stressful.
The Importance of Screening: Awareness and Prevention
Have you seen an increased awareness of colorectal cancer screening in recent years?
Screening is one of the biggest drivers in terms of prevention. There certainly have been a lot of people shining light on its importance. Generally speaking, the incidence of colon cancer has decreased over time, but there is a high prevalence of the disease. Even with the screening age for your first colonoscopy being lowered from 50 to 45, not everyone does it. I think a lot of that could be unease. People may not know their family history, so they're not attuned to their risk.
In terms of disparities, are there decreases for some demographics while others still increase?
There are certainly differences. We've seen over time that while the incidence is decreasing for Black patients, it's not decreasing at the same rate as for non-Hispanic white patients. It’s much slower. The diagnosis at the time of presentation is much different for Black patients than it is for non-Hispanic white patients. Rates of incidence are 20 percent higher, and mortality is 40 percent more likely.
It’s important to focus not only on patient education but also on the social determinants of health, how people access healthcare, and the barriers: cost, transportation, socioeconomic status, systemic issues, access to care in general, et cetera. It will depend on coordinated outreach to patients, especially those underserved or under-resourced. We need to double down on our commitment to making sure that everyone can get access to the care that they need. That’s something I am committed to at Columbia.
Innovations in Minimally Invasive and Robotic Surgery
What’s new in the management of benign disease?
The biggest growth is probably in the way we approach operations with minimally invasive surgery. More and more colorectal surgeons are doing robotic surgery. It has many benefits, like [faster] patient recovery, so more and more surgeons are adopting a robotic platform for different disease processes. And I think as that experience grows, the training follows, right?
If we're doing more robotic cases, then residents will be exposed to more robotic cases as well. Proficiency has increased. When I was a resident, there wasn't really any exposure to robotics, and I'm not that old. Now, I expect every resident in our program to graduate with a proficiency in robotics.
In the spirit of innovation, what are you excited about for the future of colorectal care?
One of the most exciting new innovations in colorectal surgery is something called transanal total mesorectal excision (TaTME), which is approaching the dissection for rectal cancers from a different angle. Instead of a primarily abdominal approach, surgeons operate through the anus initially. You remove the mesorectum [the fatty tissue surrounding the rectum], and lymph nodes. It’s really exciting because not every patient is built the same, and sometimes these dissections can be challenging, but surgeons are able to do more in these complex cases and do it better.
Even with inflammatory bowel disease (IBD), we're constantly learning about different techniques for bowel conservation, reconstruction and anastomotic techniques.
Will you briefly explain the new ways you’re approaching IBD treatment?
Sometimes, people with Crohn's disease, which is under the umbrella of IBD, may develop strictures or narrowing in the bowel that cause a lot of obstructions, nausea, vomiting, and pain. Since we don't have a cure for Crohn's, we have to intentionally preserve as much bowel as we can because it's possible that patients may have repeated episodes of strictures or inflammation or things that require surgical intervention.
One of the approaches you can use instead of removing the portion of the bowel is what's called a strictureplasty. There are different techniques, but you're basically opening up the bowel and closing it in a different configuration so that the lumen [opening] is wider and will allow things to flow through. The principle is really the same as bowel-preserving surgery. It involves thinking about how surgery may impact the recurrence of strictures or IBD in the bowel. If we're using staples or sutures, that foreign material may actually lead to recurrence over time. These techniques take into account the individual anatomy and the placement and configuration of sutures and staples.
Have technological advances helped with these complex approaches? What are some ways to plan surgically for a patient’s individual anatomy?
It really all comes back to that multidisciplinary approach, especially with IBD. Gastroenterologists and surgeons collaborate on medications and surgical options. I really lean heavily on my radiology colleagues to help me plan an operation.
I'm constantly amazed about the things I can ask my radiology colleagues to do, ask them to find, and how they can help me in different ways. Cross-sectional imaging, either with CAT scans or MRI, has really come a long way, especially in how we can visualize specific elements of inflammatory bowel disease. We can see areas of inflammation, structuring, and how it relates to the overall bowel.
Is a deeper understanding of biochemistry bringing about new medical treatments for IBD?
Throughout the last five to 10 years, it's been incredible to see how many different kinds of medications have come to market for IBD. A lot of these have different mechanisms of action, which means we’re drilling down on a more granular level. But also, we’re exploring more granular questions. How does the gut microbiome affect complications that we may see from colorectal surgery? How does it affect the risk of developing different kinds of pathology in the colon and elsewhere in the GI tract?
Looking Ahead
What are your goals for the next five to 10 years?
It’s really about tapping into resources and building bridges. So many people are doing such great work across this institution. AI is the big thing now in both clinical research and education research. It'd be great to consider partnerships with the School of Engineering, Public Health, and different centers that may focus on artificial intelligence and incorporating that technology.
More broadly, I want to build relationships. Advance how we support and mentor younger colleagues and those in training. Develop programs that create a balance between clinical work and education for residents and fellows. Focus on targeted interventions for the endemic problem of burnout. And then there’s equity and representation—our learning environment and clinical work environment should reflect the patients that we serve—being thoughtful about how we fill position shortages and the composition of our workforce in the broadest sense.
Related:
- What You Need to Know about Colorectal Cancer
- Columbia Researchers Seek Answers for Rise of Colon Cancer in Younger Patients
- What is Interventional IBD?