A Bond of Trust, a Path to Healing  ̶  Conquering Rectal Cancer

Patti Lyons, 61, of Doylestown, is the proud owner of Peace Valley Lavender Farm. She enjoys an active lifestyle, cultivating acres of lavender, greeting visitors, and overseeing the farm's retail gift shop. Patti also practices and teaches Aikido, a martial art she and her husband have enjoyed for thirty years and counting.

Five years ago, she began to experience blood in her stools, mild constipation, and weight loss. She consulted with gastroenterologist Sandhya Salguti, MD, who then performed a colonoscopy. This procedure is still the gold standard for detecting colon polyps and colorectal cancer.

Using a long, flexible scope while Patti was asleep from the sedation, Dr. Salguti examined the lining of Patti's intestines.  She then discovered a mass in Patti's rectum. Additional imaging studies showed that the cancer had spread to nearby lymph nodes, indicating a stage 3 rectal cancer.

Fighting Rectal Cancer Together

Dr. Salguti arranged for Patti to meet Robert Akbari, MD, a board-certified, fellowship-trained colorectal surgeon, to discuss treatment options.

"My first appointment with Dr. Akbari was powerful," recalls Patti. The reality of her diagnosis was sinking in, and she found his professionalism and warmth reassuring.

"He laid out a roadmap for a proven protocol to treat stage 3 rectal cancer that would take about a year to complete," says Patti. "As he went over the steps of the treatment plan, I could imagine myself going through the process and coming out on the other side in good health."

Patti's Team of Experts

"We often use chemotherapy, radiation, and surgery together to treat rectal cancer effectively," says Dr. Akbari. However, he notes that with newer protocols some patients nowadays even avoid surgery, depending on circumstances.

Patti began her treatment with chemotherapy under the care of Mitch Alden, DO, a medical oncologist, and a course of radiation therapy under the care of Sonal Mayekar, MD, a radiation oncologist. The goal is to shrink the tumor and eliminate or reduce cancer in the lymph nodes ahead of surgery. "We call it downstaging," explains Dr. Akbari. In some cases, a person can have a complete response, meaning that all evidence of the person's cancer may be eliminated.

"I had a team of rectal cancer experts working together to treat my medical condition," says Patti. 

"We collaborate to ensure that every patient gets the appropriate care," says Christopher Bruce, MD.  Dr. Bruce is the Medical Director of Doylestown Hospital's nationally-accredited Rectal Cancer Program. "We follow the latest national guidelines to create personalized treatment plans," he says.

"I am honored that Mrs. Lyons put her faith and trust in me, my colleagues, and Doylestown Hospital," says Dr. Akbari, “Our rectal cancer team includes pathology, radiology, radiation oncology, medical oncology, genetic counseling, and wound/ostomy specialists. We also have a colorectal nurse navigator, Marianne Haig, RN, who can help expedite imaging and office appointments, provide access to support services, and offer guidance through diagnosis, treatment, and recovery.”

Nationally Accredited for Rectal Cancer

Doylestown Hospital recently earned a three-year accreditation from the National Accreditation Program for Rectal Cancer (NAPRC), a quality program of the American College of Surgeons. Only four hospitals in Pennsylvania hold this prestigious distinction, and ours is the only one in Bucks County.

"When you are dealing with cancer, you don't need extra stress," says Patti. She appreciated having access to high-level care so close to home.

"It took me 12 minutes to drive to Doylestown Hospital. I didn't have to go to Philly or anywhere else," says Patti. She says getting to chemotherapy and daily radiation treatments was easy and that it was much less stressful for her husband to visit her in the hospital. 

Highly Personalized, Connected Care

"You don't appreciate how important it is to have this level of expertise and service close by until you need it," says Patti. The compassionate care she received and the special connection she formed with Dr. Akbari played an equally important role in her decisions about her care.

"I especially feel particularly connected to patients with a cancer diagnosis.  It’s a long challenging road and part of my job, I think, is doing my best to explain things, offer support, and to help folks like Patti see the light at the end of the tunnel," says Dr. Akbari. 

Robotic Surgery for Rectal Cancer

Using the Intuitive da Vinci® robotic surgical system, Dr. Akbari removed the affected part of Patti's large intestine and the affected lymph nodes through tiny incisions. His medical partner, Dr. Bruce, assisted. 

Like traditional laparoscopic surgery, robotic surgery is minimally invasive, using small incisions and a miniature camera. However, the robotic platform offers an enhanced 3-D view, and the instruments are more flexible. This enables the surgeon to gently manipulate tissue and place sutures in tight areas such as the pelvis.  The surgical robot is particularly useful in a narrow area such as the pelvis.  This area is crowded with significant nerves, organs, and blood vessels, which need to be navigated according to Dr. Akbari.

Patti's Ileostomy Helps with Healing

As part of Patti's procedure, Dr. Akbari temporarily bypassed Patti's large intestine by bringing the side of her small intestine through her abdominal wall outside her body. This opening is called a stoma, or more specifically an ileostomy. A special bag attaches to the opening, collecting waste outside the body.

"This part of the treatment for rectal cancer, if needed, can be daunting for patients," says Dr. Akbari. He notes that with modern techniques and treatments, most ileostomies are temporary.

One of the hospital's wound care nurses, Jeanette Delaney, RN, taught Patti and her husband about ostomy care and how to attach the bag. "My kind, loving husband helped to change my ostomy a few times a week," says Patti, noting that it was a little awkward when she attached the bag herself.

Facing a Challenge

Home again after her surgery and hospital stay, Patti was outside having a bowl of soup when she began to vomit. She went to Doylestown Hospital's Emergency Department and returned to the hospital. Her intestines were not waking up as they should, so food and digestive juices were backing up in her stomach.

"This is not typical or expected, but can happen after any abdominal surgery," says Dr. Akbari. "We treat this condition by providing nutritional support until the bowels wake up again." Since Patti was not able to take in nutrition by mouth, she received a nasogastric (NG) tube, a thin tube that went through her nose to her stomach.

"Dr. Akbari or Dr. Bruce checked on me daily," says Patti. After more than a week with the NG tube, Patti was finding it extremely uncomfortable, and she wanted it removed. "Dr. Bruce came to see me one day, and I asked him to take it out," says Patti. He did, and fortunately, her intestines began working the next day.

Wrap up Chemotherapy

At the time Patti received treatment, best practices for rectal cancer care typically called for chemotherapy and radiation (6 weeks), followed by surgery, followed by more chemotherapy (4-6 months). In Patti’s case, she had a complete response to her cancer treatment.  After recovering from surgery, the last phase of chemo was optional. 

Patti decided to go ahead with her final round of chemotherapy. "It felt like an insurance policy," she said. 

"Management of rectal cancer is always progressing," says Dr. Akbari, “In fact even more recently, patients often undergo all of their chemotherapy and radiation together upfront. If they have a complete response, with no evidence of any cancer left, these patients may opt for what is called “watch and wait.”  This means holding off on surgery and monitoring over time, sometimes avoiding surgery all together."

Reversal of Ileostomy

In January 2020, Dr. Akbari reversed Patti's ileostomy surgery. She would no longer need to wear a bag. He reconnected her intestines so she could resume regular bowel movements. After three days in the hospital, she was able to return home. 

An Enduring Connection

"Patti and her husband are very pleasant and likable," says Dr. Akbari, “I get to know my cancer patients particularly well because there are a lot of steps to the treatment." Dr. Akbari is a fan of lavender. He likes the scent so much that he visited Patti's farm before meeting her as a patient. So, Patti brings him lavender items from her shop occasionally when visiting his office.

"Dr. Alden follows her progress too," says Dr. Akbari. Surveillance after surgery includes blood work, an annual CT scan, and colonoscopies. "I still see Patti every so often," adds Dr. Akbari. "She's doing great and approaching five years being cancer-free, a major milestone."

Colon and Rectal Cancer —                      Know the Difference

The term colorectal cancer encompasses cancer of the colon and rectum, which are parts of your large intestine. "We call it colon cancer when it appears in the abdomen and rectal cancer when it is in the pelvis," says Dr. Akbari. He notes that the cell type, symptoms, and risk factors are the same for both colon and rectal cancer.

Screening for Colorectal Cancer

Doctors recommend colon cancer screening for everyone starting at age 45 — even sooner if you have a family history of it.  Screening allows doctors to detect colon cancer early, even with no symptoms. Talk to your provider about your chance of developing colorectal cancer, when you should screen, and which test is best for you.

Risk Factors for Colorectal Cancer

Your risk of developing colorectal cancer increases with age.  Your risk is also higher if you eat a poor diet (high fat, low fiber), or regularly consume alcohol and tobacco, according to the Centers for Disease Control and Prevention (CDC). Other risk factors include the following:

• A personal or family history of colorectal cancer or polyps
• Inflammatory bowel disease like Crohn's disease or ulcerative colitis
• A genetic syndrome such as familial adenomatous polyposis (FAP) or hereditary non-polyposis colorectal cancer (Lynch syndrome)

Symptoms

The CDC notes that symptoms of colorectal cancer can include:

• A change in bowel habits
• Rectal bleeding, blood in or on your stool (bowel movement)
• Diarrhea, constipation, or feeling that the bowel does not empty all the way
• Abdominal pain or aches or cramps that do not go away
• Losing weight and you do not know why

According to Dr. Akbari, not everyone shows symptoms. Some patients are not aware of having blood in the stool for example.  However, with non-obvious bleeding, anemia can still develop which occasionally leads to fatigue. 

"This is a benefit of colonoscopy," he notes, “Even if there are no obvious symptoms, a colorectal cancer may be found.”

Screening Tests

Colonoscopy

Screening tools like colonoscopy are highly effective in detecting and preventing colorectal cancer. A colonoscopy provides a high detection rate in picking up colorectal cancer.

During a colonoscopy, the gastroenterologist uses the scoping instrument that consists of a tube with a camera on the end to look at the entire colon and rectum.

Colorectal cancers start as polyps, so your gastroenterologist will look for evidence of them. Once spotted, the gastroenterologist will remove any concerning polyps, thus preventing colon cancer from developing. If your doctor finds polyps, you will need a repeat colonoscopy every three to seven years. If your doctor does not find any polyps, most people do not need another colonoscopy for ten years.

Cologuard®

Cologuard is another screening test for polyps and colorectal cancer.  It is best used in individuals without symptoms or a family history of polyps or colorectal cancer, who wish to avoid colonoscopy. This at-home stool test can pick up abnormal DNA in your stool that sheds from polyps, especially bigger ones. It also identifies blood in the stool.  You may need to repeat this test every three years.

FIT Test

Another screening test that can identify colorectal cancer and is less invasive than a colonoscopy is the FIT test (fecal immunochemical test). It uses antibodies to detect blood in the stool. This sensitive test goes to a lab for analysis, and it should be done annually. Doylestown Health Colorectal Specialists and Doylestown Health Gastroenterology provide screenings and an Open Access Colonoscopy Program. This program allows healthy patients without exclusion criteria to schedule a colonoscopy without an initial office visit.

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