Michael Calderone, walking with his wife Caroline, had his colorectal cancer removed without the need for an incision.
Patients experience better quality of life, thanks to less invasive and more targeted approaches in cancer care being pioneered at Sunnybrook
The tea came in a little plastic cup, oversteeped and slightly tepid. But it didn’t matter to Michael Calderone. |
Things could have been very different. Michael and his wife, Caroline, had previously been advised that treating the colorectal cancer in his rectum would require cutting through his abdomen to remove the rectum and surrounding lymph glands. They would also need to create an ostomy pouch – also known as a permanent colostomy bag – to collect his waste.
"And if all was to go well with the surgery and my recovery, I would have to come back later to get the sphincter and colon reattached," says Michael, a Toronto entrepreneur who runs a wholesale and retail fashion business. "But healing could take months. And there was a chance that reattachment would not be possible, and I would have to live with a colostomy bag."
Michael Calderone was able to leave hospital on the Photograph by Tim Fraser |
The Calderones then met with Dr. Shady Ashamalla, a surgical oncologist at Sunnybrook's Odette Cancer Centre with expertise in minimally invasive laparoscopic surgery for cancers in the lower gastrointestinal tract. Dr. Ashamalla suggested a "trans-anal minimally invasive" approach which would use tiny instruments in tandem with a laparoscope (tiny video camera) inserted through the anus to remove the cancer.
"There's no incision at all," explains Dr. Ashamalla, who completed advanced fellowships in both minimally invasive surgery and surgical oncology as part of his training. For this relatively new procedure, which is suitable for removing early stage colorectal cancer and non-cancerous polyps in the rectum, he studied with leading surgeons in the field. "Instead of cutting through the abdomen, we go through a natural opening in the body, cut out and remove the tumour, and patients can go home the same day."
In Michael's case, he had a small, early stage colorectal cancer low in the rectum that was removable by local excision. By 3 p.m. on the day he had his trans-anal surgery, he got up, held his wife's hand and walked out of the hospital.
"I had the surgery on Friday," recalls Michael, who must now come to Sunnybrook every three months for monitoring over the next two years. "On Monday, I went for a five-kilometre walk."
| MINIMALLY INVASIVE |
Most treatments to remove and destroy cancer come with physical risk.
To ease the physical burden on patients already dealing with cancer, doctors and scientists at Sunnybrook have continued to advance innovative treatments and approaches that are less invasive than conventional procedures. These approaches zoom in on the cancer while sparing the rest of the body.
Michael's surgery is just one example of minimally invasive cancer treatments offered today at Sunnybrook.
"Minimally invasive treatment is not just a technique, it's a philosophy of care at Sunnybrook," says Dr. Ashamalla, who is a member of the Odette Gastrointestinal Cancer Care team.
From pharmaceutical agents that target molecular abnormalities specific to pancreatic cancer to using sentinel lymph node biopsy (or the removal of only the first lymph nodes (sentinel nodes) into which a primary tumour drains) to detect metastases in cervical cancer, Sunnybrook is continually expanding its repertoire of procedures that minimize the physical impact on patients while delivering the same or better outcomes than traditional approaches.
Sunnybrook offers laparoscopic surgeries, where appropriate, for the care of gastrointestinal and some gynecological cancers. These procedures involve a few small incisions with ports placed through the incisions. Using a laparoscope as a visual guide, the surgeons skillfully manoeuvre long, thin surgical instruments to remove tumours without injuring any areas of the body.
Minimally invasive treatment is Photograph by Doug Nicholson |
"Our goal is to be able to offer procedures that can be done in the least invasive way, but, at the same time, achieve the same oncological effect to remove all the cancer," says Dr. Ashamalla, head of general surgery at Sunnybrook.
Mary Abbott underwent a laparoscopic colon resection.
"I was diagnosed with colon cancer in January 2013, and it was not early stage – I had almost a full blockage," says Mary, a lawyer and partner with a large Toronto law firm. "When Dr. Ashamalla said the cancer could be addressed minimally invasively, I was surprised, but definitely relieved at the idea of not having full open abdominal surgery."
Mary, a mother of two boys aged
12 and nine, went in for her laparo-
scopic surgery on a Wednesday and went home two days later. While she didn't go back to work for a while, she says she resumed normal activities shortly after the procedure.
"I continued to see my friends and exercise and hang out with my kids," says Mary, who also received six months of chemotherapy and now comes in for regular checkups to ensure she remains cancer-free. "Because you don't have that pain associated with a larger incision – I probably have four tiny incisions that you can't even notice – you forget that you just had major abdominal surgery, and that really allows you to get back to normal quicker."
| TARGETED APPROACHES |
Surgical oncologist, Dr. Paul Karanicolas, and medical oncologist, Dr. Yooj Ko, also of the Odette Cancer Centre Gastrointestinal Cancer Care team, have collaborated to bring to Sunnybrook a first-in-Canada Hepatic Artery Infusion Pump Program. This is a promising approach, still in clinical trial, for patients where colorectal cancer has spread to the liver, with immediate surgery being too risky, and where first-line chemotherapy to reduce tumour number and size is proving unsuccessful in order to make liver surgery possible.
Christy Pieroway of Newmarket, Ont., is a 43-year old mother of two and a former globe-trotting sales representative. She is one of a small number of participants in this trial, which researchers hope to offer to more patients.
Diagnosed with colon cancer that had spread to the liver, Christy immediately had surgery in August 2013 at a local hospital to remove the tumour in her colon. She then underwent standard chemotherapy to limit further spread and to shrink the tumours in her liver.
Christy was subsequently referred to Sunnybrook's Odette Cancer Centre for liver surgery. In reviewing her case, the multidisciplinary team that included surgical, medical and radiation oncologists, pathologists, interventional radiologists and oncology nursing, recommended she would be a good candidate for the Hepatic Artery Infusion Pump trial as immediate liver surgery was not possible.
The Hepatic Artery Infusion Pump is a small disc-shaped device that directs anti-cancer drugs into the liver through a catheter inserted into the organ's hepatic, or main, artery. The pump is implanted beneath the skin just above the abdomen. Chemotherapy is infused in the pump at regular intervals, at about two to six weeks apart.
The hepatic artery supplies most of the blood to cancers in the liver, says Dr. Karanicolas. Because of the liver's ability to clear out toxins, any leftover drugs not delivered to the cancer cells get eliminated, leaving other parts of the body free of the drug and related side-effects.
"So most of the chemotherapy – about 95 per cent – actually stays in the liver, to treat the tumours," he says.
The liver-directed chemotherapy via the pump is given in combination with standard intravenous chemotherapy. To date, combined treatments have yielded a positive response of reduced metastases of up to three times, or 75 per cent, greater than standard second-line chemotherapy alone.
Fast-forward to the present: Christy and Drs. Ko and Karanicolas have seen in the latest CAT scans a reduction in the tumours in Christy's liver and, most recently, indications that the cancer is not changing over time.
"We are excited about Christy's prospects, especially now that we are also seeing cancer control," says Dr. Ko.
"The program requires strong collaboration among a large group of specialists. It offers appropriate patients a more effective and targeted treatment option, and we hope to expand the program," says Dr. Karanicolas.
"The pump had initial challenges for me, but the results have been encouraging," says Christy, "and knowing Sunnybrook's team is behind me, helping me all the way, it's renewed our hope for the longer term."
This content was produced by The Globe and Mail's advertising department, in consultation with Sunnybrook. The Globe's editorial department was not involved in its creation.