Ask the Doctor @ Get Your Rear in Gear: Dr. Jordan Berlin discusses Avastin, cancer screening, and issues of heredity

Jordan Berlin, M.D.

This month, Ask the Doctor @ Get Your Rear in Gear, heads south to Vanderbilt University in Nashville, Tennessee to talk to accomplished gastrointestinal oncologist Dr. Jordan Berlin.  He answers a wide range of questions brought to our attention by colon cancer survivors. Dr. Berlin also discusses the importance of diet and exercise in maintaining good health.

Dr. Berlin is an Associate Professor and Clinical Director of Gastrointestinal Oncology at Vanderbilt University Medical Center in Nashville, Tennessee.  He is also the Medical Director of the Cancer Center Clinical Trials Office at Vanderbilt Ingram Cancer Center.  He is the Co-Principal Investigator of the Vanderbilt GI SPORE and Co-Director of the Vanderbilt-Ingram Cancer Center GI Oncology Program, a highly esteemed research program that promotes interdisciplinary research and moves basic research findings from the laboratory to clinical settings.  Dr. Berlin earned his medical degree at the University of Illinois, Chicago, followed by an internship and residency in internal medicine at the University of Cincinnati Hospital and a medical oncology fellowship at the University of Wisconsin Hospital and Clinics in Madison, Wisconsin.  Dr. Berlin has earned several awards including the Section of Hematology/Oncology Teaching Award in 2003 and the Eastern Cooperative Oncology Group Young Investigator Award in 2004. He has authored or co-authored over 50 peer-reviewed journal articles, 7 book chapters, and over 100 scientific abstracts.  As an invited speaker to many worldwide symposiums, Dr. Berlin lectures on the treatment of several gastrointestinal cancers including the treatment of colorectal cancer.

Get Your Rear in Gear: Dr. Berlin, thank you for taking the time to be a part of the Ask the Doctor series. The Colon Cancer Coalition’s website and their general mission is “Get Your Rear in Gear” which is a message about getting screened for colon cancer, but also about maintaining healthy lifestyle habits.  Do you talk to your patients about issues related to general health such as exercise and eating right?

Dr. Berlin: Yes, I do. I’m not soft on the issue of obesity.   In fact, recently I had a patient who lost 30 pounds just to prove to me that he wasn’t fat. I told him he was overweight and he disagreed.  So he walked out of my office and lost weight just to prove to me that he was right. But as a general rule, patients are receptive to the discussion about exercise and eating right. It’s an important issue here in Tennessee.  This year we were ranked the sixth unhealthiest state in the country, an improvement from last year when we ranked third.

Regarding screening, I can talk to my patients from personal experience.  I had my first colonoscopy screening at 45 because I have a mother who had colon cancer.

Get Your Rear in Gear: Are you an exerciser?

Dr. Berlin: Yes.  I walk my dogs 3 to 8 miles everyday. I have a Great Dane and a mutt, both dogs I rescued from an animal shelter.  On the weekends, I take the dogs on longer hikes.   I also go to the gym 3 to 5 times per week.

Get Your Rear in Gear: Do you follow any particular diet or nutritional guidelines?

Dr. Berlin:I eat five to nine servings of fruits and vegetables every day.  I’ve cut my sugar intake significantly and I’ve also cut back on red meat.  I don’t drink coffee and I include a decent amount of fiber in my diet by eating plenty of whole grains.  But mainly, I focus on getting my daily servings of fruits and vegetables, and I buy organic when I can.

Get Your Rear in Gear: We had several detailed questions from readers this month, including this one about Avastin, a cancer medicine that is used to treat certain types of tumors. It is often used in combination with other medications.  She writes:

“As a survivor, I would like to know how successful adding Avastin to treatment has been for people like me who had their cancer spread to another organ.  When my colon cancer spread to my left lung, my second round of chemotherapy included Avastin in addition to the 5FU, Leucovorin, and CPT-11.  Thankfully I have not had another recurrence, and I’m sure the Avastin played a role in that fact.”

Dr. Berlin: In multiple randomized trials, chemotherapy has been shown to be more effective with the use of bevacizumab (Avastin). The amount of benefit has varied by study so it’s impossible to figure exactly how it may have impacted your case.  How exactly does it contribute to the improved survival of patients?  They haven’t been able to figure that out. But we know that it helps.

Get Your Rear in Gear: The next question comes from a mother who is concerned about how her family’s health history should affect screening for her son.  She writes:

“I was diagnosed with Familial Polyposis at the age of 14 and I had a total abdominal colectomy. I was told that if I had a daughter that the chances of her developing this form or cancer would be almost guaranteed. This form of cancer has only been diagnosed in girls on my mothers side all the way back to my great grandmother. That’s why they were concerned about a daughter.

My son at the age 21 was diagnosed with colon cancer and had surgery to remove it.  Eight months later he developed gastric cancer and it spread in a matter of months from his stomach to every place it could go.  On January 11, 2002 he passed away.

Is there any way my older son can see if he is a carrier of this Familial Polyposis without a colonoscopy? He is 26 years old.”

Dr. Berlin: The simple answer is yes.  Most comprehensive cancer centers offer genetic testing, and in this case we have already identified the abnormality. Familial Polyposis is autosomal dominant, so it only has to be present in one chromosome to cause the disease.The first person who needs to be tested is her.  If we can pick up the abnormality in her, then her son can be tested.  If he has it, he will need to have a colonoscopy every year.  If we can’t pick up the abnormality in her, we can’t pick it up in her son and he will need to have colonoscopy to assess for the polyposis.

Get Your Rear in Gear: And finally we have a multi-part question about pursuing different testing methods after a cancer diagnosis.

“What tests should I rely on when screening to see if my colon cancer, or cancer in general, returns?  When I went in to surgery to remove an 8″ cancerous tumor that grew one year after a completely clear colonoscopy that I had when I turned 50 as part of a normal 50-year exam, my CEA blood test showed a 1.95.  After surgery, and a short bout of chemo the CEA test was 2.50.  Now six months later, my CEA blood test shows 1.30.  If all of my CEA tests were in the normal range, even when I had cancer, how can I trust this test?  What is this test telling me?  Should I trust it and if it does show above 3.0 (which is what I am being told is an indicator that something may be brewing) won’t that be too late?”

Dr. Berlin: The issue is that with colon cancer, no test is perfect.  A colonoscopy picks up almost everything when it comes to large polyps and many, but not all flat adenoma polyps, but some cancers can grow in a short period of time.  CEA is not a perfect test.  It is likely that if your CEA level was high initially then it would rise again in subsequent tests (if cancer was present).  Current guidelines recommend colonoscopy screening for a second cancer one year after diagnosis, then every 2-3 years after that.  CT scans are recommended once a year for the first three years. The CEA test is recommended every three months for three years, then every 6 months until 5 years after diagnosis.  The vast majority of cancers will come back in the first three years, but there are some that will come back even after that point.

“After surgery, I now have an area near where the section of my sigmoid colon was removed which I am aware of every day.  It is a burning, pulling sensation, which worsens if I exercise.  My doctors have all said it is probably a result of surgery, possibly scar tissue.  I am being told because it is in the tissue area of my abdomen a CT scan would not necessarily show anything.  How can I be sure what this is?  What if it is cancer?  My cancer was Stage IIA with no indication of spread to other tissues or to the lymph nodes.”

Dr. Berlin: Stage II in general has a good prognosis.  In terms of the specific sensations mentioned, symptoms are hard to diagnose, and of course they are particularly hard to diagnose in this kind of Q & A format.  The doctor caring for this patient may know a lot that is not being said here so I can’t really comment on the symptoms mentioned.  When a person has symptoms, there is always a chance that there is something present causing those feelings, and even a CT scan could miss it. We do CT once a year as per the guidelines.  We also tend to do a CT if there is a symptom that we are concerned about.  If CT doesn’t catch anything, then it may be reasonable to add a PET scan.  Lastly, a colonoscopy may also be indicated based on the symptoms experienced.

It’s nearly impossible to be completely certain of anything in these situations.  And not necessarily being sure of something is a difficult thing in cancer.

“I still have minor symptoms that I had when I had cancer in my colon.  Upset stomach when I eat, difficulty in having bowel movements.  Will I ever be normal again?  The last colonoscopy I had 4 months ago was clear.”

Dr. Berlin: It is hard to predict what is going to happen. A lot of people have bowel and digestive issues after surgery.  Many return to normal after a period of time.  Unfortunately, there is no way to predict with certainty how a patient will fare after treatment.

Do you have a medical question?

Each month the Colon Cancer Coalition interviews a noted physician about good health, fitness, diet and medical conditions related to the treatment and diagnosis of colon cancer. Got a question?  Let us know! Click here to send your questions to the doctors.