Hold On To Your Butts!
Are we close to eliminating surgery for rectal cancer?
Hello everyone! Still time to talk to your doctor about colorectal cancer screening! Don’t delay and bring a friend. The colonoscopy prep is exactly as bad as everyone says but radiation for rectal cancer is worse! Seriously.
Thanks for reading and if you are so inclined, please share this post with a friend. There’s always room at our table.
Of the many lines delivered by Samuel L. Jackson, this one from the original Jurassic Park has always stuck in my mind. If you remember the scene in the movie when he utters these words, the humans are trapped inside a compound with hordes of genetically engineered dinosaurs roaming outside. Jackson’s character finishes reprogramming the electric fence and is preparing to power up the new system.
Jackson slowly flips each switch. He pauses before flipping on the main power, burning cigarette dangling from his lips and delivers the classic line, “Hold on to your butts.”
A brief refresher on anorectal anatomy
The anus and rectum are areas where waste leaves our bodies. This is controlled by internal and external valves called sphincters.
The internal sphincter is what we don’t control. It basically keeps us from soiling ourselves while we go about our normal lives. The external sphincter is the “Oh shit!” moment we have all felt when that questionable chicken salad has finished it’s processing in our GI tract and is ready to leave the body. NOW. We have some control over this external valve, but we’d better get to a bathroom soon. Learning the meaning behind these sensations is part of the process of “potty training” children.
Cancers in this area can affect the function of these sphincters and even after treatment, scar tissue in this area can prevent the sphincters from forming a tight seal. In addition, cancers too close to the sphincters can’t be removed without removal of the sphincter thus necessitating an alternative method of removing stool from the body- a colostomy, colloquially called a “bag.”
Discussions of cancers “down there” can be fraught with societal expectations, trauma and internalized shame. An understandable mix of denial, hope and lack of awarenss often leads patients to put off evaluation. In young patients, I’ve seen delayed diagnoses due to assumptions that rectal irritation or bleeding is just hemorrhoids. That a 30-year-old is “too young” for cancer.
In older patients, I’ve seen large tumors grow to the size of golf balls when no one wants to ask sweet old grandma to take her pants off so they can take a look to see what’s causing her rectal pain.
I understand. Grade school jokes aside, not many people openly want to discuss their bowel habits and we all hope that we will remain forever continent without the need for an external ostomy or protection from leaking. Fear of what will be left when/if we seek care for cancer can be a powerful motivator to cross our fingers and hope for the best. In colorectal cancer, patients are often afraid of how surgery will impact their bowel habits, often saying they would rather die than have a “bag,” a statement that is almost always not true once the shock of a diagnosis wears off.
We have come a long way in colorectal cancer but until recently, treatment was basically still as it was from the early 1990s.
A short history of rectal cancer surgery
In 1826, French surgeon Jacques Lisfranc surgically removed a tumor of the low rectum through a perineal approach, basically from the bottom inward. Although the cancer was completely removed, the absence of both sphincters left the patient with “uncontrollable excretion” of feces. In a report to his colleagues, he described his procedure and reported it as a success although the mortality rate after surgery was about 30%, mostly from infection.
A few years later, British surgeon W. Ernest Miles showed that in patients who survived, the cancer commonly came back. Miles developed the earliest form of the abdominal perineal resection or “APR,” the basis of current rectal cancer surgery. The only problem? About a third of his patients also died during or soon after surgery.
A few years after Miles’ report, the routine use of anesthesia (yes. Think about that. The early patients were undergoing REMOVAL OF THEIR RECTUM THROUGH THEIR ANUS without anesthesia), antibiotics and placing the patient’s legs in stirrups during the operation to improve access to the tumor significantly reduced this death rate and improved cancer cure.
It was not until the 1950’s when Mayo Clinic surgeons perfected an operation that allowed preservation of the anus and formation of a colostomy which is called an abdominoperineal resection (APR). Over the ensuing years, surgeons developed treatment regimens that now allow some patients to keep their sphincters but also to avoid colostomies. This surgery, called a low anterior resection (LAR), is associated with equal survival, cancer control, and better quality of life than the APR.
Administering chemotherapy or chemotherapy and radiation before surgery has allowed many patients to only have an ostomy temporarily or avoid one altogether. Different recipes of chemotherapy have improved survival rates and prevented cancer from spreading to other areas of the body.
What gives me hope today
It was kind of status quo, however, until last summer when a study of 12 patients was published in the prestigious New England Journal of Medicine study. This tiny study generated quite a buzz. I know this because my college age stepdaughter sent me a video that she saw on TikTok explaining the study.
Did you know about this? she asked. Thank goodness, I did. Is it possible someday doctors will be learning about medical advances from TikTok, I wondered.
Doctors at Memorial Sloan Kettering Cancer Center in New York City treated twelve newly diagnosed advanced rectal cancer patients with six months of a new monocolonal antibody called dostarlimab. This is a medicine that unmasks cancer cells so that the body’s immune system could find and kill them.
All patients were supposed to go on to have standard treatment with chemotherapy, radiation and surgery. However, when the doctors noted the dramatic response, they did not go on with the “normal treatment” and instead observed the patients. This type of response to a single medication is unheard of and remarkable. The study is ongoing and long-term results have not been reported.
This is the type of research that gives me hope that in the near future many colorectal cancer patients will finally be able to safely avoid surgery. Hold on to your butts, indeed.
That’s exciting news. Exposing them then the body stands a fighting chance. This is the kind of approach to cancer i hope can be applied to many other cancers. Thank you for writing about this.