Immunotherapy: When is sooner better than later?
JUST AFTER LABOR DAY in 2019, Sascha Roth, who was 38 years old, was diagnosed with stage III rectal cancer. Roth co-owns and operates Urban Country Designs, a furniture and interior design company in Bethesda, Maryland. After noticing some rectal bleeding, she had a sigmoidoscopy, and a growth in her rectum was removed. When her gastroenterologist called to let Roth know that the growth was malignant, the small-business owner’s first instinct was to gather extra information from a friend who was diagnosed with colorectal cancer two years earlier.
Her friend, who had surgery at Memorial Sloan Kettering Cancer Center in New York City, recommended that Roth make the trip north for a consultation in addition to going to the cancer center close to her. Typically, treatment for stage III rectal cancer includes some combination of radiation, chemotherapy and surgery. In many cases, oncologists recommend starting treatment with chemotherapy and radiation to shrink the tumor before surgery—an approach known as neoadjuvant therapy.
Surgery for rectal cancer can involve removing the rectum, which means a person might need an ostomy bag, either temporarily or permanently. After surgery, “gastrointestinal function is never the same,” says physician-scientist Luis Diaz Jr., a medical oncologist at Memorial Sloan Kettering. Radiation also carries the risk of long-term effects including incontinence and problems with sexual function.
Roth tried to assure herself that she would handle whatever treatment she needed, but after genetic testing at Memorial Sloan Kettering, she learned she had Lynch syndrome, an inherited condition that is caused by mutations in DNA mismatch repair genes. When functioning normally, these genes help correct mistakes when DNA is copied. People with Lynch syndrome have increased risk of developing many cancers, including colorectal cancer. Roth’s oncologist, Andrea Cercek, didn’t recommend chemotherapy. She noted that some research suggests chemotherapy doesn’t work as well in patients who have tumors like Roth’s, which are considered mismatch-repair deficient. In addition, Roth’s tumor was located low in her rectum, which meant she would likely need a permanent ostomy bag after surgery.