Screening for heredity colon cancer: The privilege and responsibility of the surgeon

Zane Cohen, MD, FACS, FRCSC
Zane Cohen, MD, FACS, FRCSC

“When I saw that Dr. Bass’s theme for this Clinical Congress was the Joy and Privilege of a Surgical Career, it made me think of what I could say to fit in with this particular theme,” said Zane Cohen, MD, FACS, FRCSC, who presented Tuesday morning’s Herand Abcarian Lecture, Privilege and Responsibility: A 20-Year Journey.

“I don’t think there is any doubt that it is a tremendous privilege to be a surgeon … and that privilege comes with a certain responsibility,” said Dr. Cohen, director, Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, and professor of surgery, University of Toronto, ON. “Patients trust their whole body to you … and we should never forget that as a surgeon.”

Dr. Cohen’s presentation started on a personal note in which he described himself as a Lynch syndrome family member. His niece, Karen, had been found to have dysplasia in the endometrium, and it was decided that she was in need of surgery. About an hour into the procedure, the surgeons came out to the waiting room and spoke to Dr. Cohen and his sister, revealing that Karen had metastatic disease of the pelvis and they recommended closing her and offering her chemotherapy.

“I said this is a localized disease in the pelvis and we should try to take it out, and they finally compromised, offering to biopsy a node, and if it was negative, they would do the surgery, which they did,” explained Dr. Cohen. “They tested the tumor and she had Lynch syndrome, and the whole experience set me off. Being a surgeon is a privilege and a responsibility, but even after operating on so many people, I didn’t know what was going on with my own niece,” he said.

As a result of this experience, Dr. Cohen embarked on an investigation of his extended family, developing a pedigree that mapped out relatives who had cancer, those who tested negative, those who were carriers, and members who refused testing or who were not tested (deceased). “What you can learn from your own family can be transposed to your patients with Lynch,” he said.

“Lynch syndrome is an inherited cancer susceptibility syndrome that is characterized by familial clustering of other cancers, including colorectal and endometrial. The syndrome is secondary to autosomal dominant inherited genetic mutations in one of the mismatch repair genes, including MLH1, MSH2, MSH6, PMS2,” said Dr. Cohen, noting that several organizations have written Lynch syndrome guidelines, including the National Collaborative Cancer Network, the American Society of Clinical Oncology, and the American Society of Colon and Rectal Surgeons.

Regarding preventative strategies, Dr. Cohen cited the CAPP 2 trial (colorectal adenoma/carcinoma prevention program), a U.K.-based study of 937 individuals with Lynch syndrome who ingested 600 mg of aspirin versus placebo every day for a minimum of two years. “The evidence is clear, at least in Lynch syndrome, that aspirin is a major factor in reducing colorectal cancer,” he said.

“I predict we will know more about risk associations, particularly with multi-gene panel testing. We need to be aware of how Lynch syndrome and these cancers can be associated in order to be sure we are doing what is best for our patients,” Dr. Cohen said.

The Herand Abcarian Lecture was established by the Chicago Society of Colon and Rectal Surgery in 2006 to honor Dr. Abcarian, a colon and rectal surgeon, and to address issues of relevance to the surgical community at-large and focus on emerging issues in surgery. The Named Lecture is sponsored by the Advisory Council for Colon and Rectal Surgery.