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Kinder, gentler test for colon cancer

Winnipeg doctor opens up about treatment

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Earlier this year, Dr. Frank Plummer found out he had cancer.

Plummer is the scientific director of Canada's National Microbiology Laboratory in Winnipeg. His is a busy job that has him shuttling several times a month between Winnipeg and Ottawa, home of the Public Health Agency of Canada.

After experiencing gastrointestinal symptoms for about six months, he had a colonoscopy in March. It revealed he had a large polyp -- in his rectum. The polyp was removed and sent to a lab. The results showed the polyp contained cancerous cells.

Though the growth had been removed, Plummer, 59, was told the chances were good he might harbour cancer cells.

"They couldn't really tell from the pathology whether there'd actually been any invasion of the muscle and the colon itself," he said.

Plummer wasn't keen to undergo the procedure that traditionally would have been done to explore whether the cancer had spread. It would have involved a major incision across the abdomen and would have meant weeks of recovery time.

He had even more concern about another possible outcome. It might have required his surgeon to resection the bowel. As a result, he might have needed a colostomy, an opening in the abdominal wall through which stool drains into a bag.

Not so long ago, Plummer's other option would have been to elect to have doctors monitor him for signs the cancer has spread and only deal with the situation if the need arose.

"I think if they had said, 'Well, you need to have it out and we're going to cut you open and you may end up with a colostomy,' I might not have done it. I would have just had them monitor it carefully," he admits.

But then another option was put on the table. Plummer was informed he could elect to have a surgical procedure that uses the anus as the entry point. "I was astounded when I heard about it," Plummer admits.

And so on Aug. 28, Plummer had the procedure performed at Victoria General Hospital. His surgeon, Dr. David Hochman, used an endoscope equipped with a camera to locate the polyp scar on the rectal wall, then punched out a seven-centimetre piece of tissue.

The pathology report showed the tissue had no sign of cancer. He doesn't need followup chemotherapy or radiation, though he will be closely monitored for the next few years.

Hochman says that while this surgical approach isn't right for everyone, it was a good option for Plummer.

"We prevented a big operation for him," says Hochman, who is one of a small but growing number of surgeons using this approach, called trans-anal endoscopic microsurgery, which goes by the acronyms TEM or TEMS.

"This is really one of those rare situations in surgery where we really have a better mousetrap than what we had before."

The procedure Plummer avoided by opting for the trans-anal surgery would have required a seven- to 10-day hospital stay and a month off work. It also would have involved a lot of pain.

"We've done a strategic strike in a sense," Hochman says.

"We've taken that scar where we know the polyp was, we took a margin around that entire scar, we cut deep into the rectum and the fat around the rectum, making sure if there are already roots we get underneath them, and what we were able to give the pathologist is this beautiful disk of tissue which included the rectal wall, the rectal muscle and the peri-rectal fat and they can look at any way they wanted to."

The camera in the endoscope projects images onto high-definition TV screens in. Hochman, who has done more than 100 such surgeries, says the learning curve is steep. Operating in such a confined area requires good laparoscopic surgery skills.

The procedure is far less invasive for a patient. "What that means is by going through the rectum and operating within the rectum ... the body really doesn't even know you were there," Hochman says. "They wake up. They have real lunch or real dinner and they can go home."

Less time in hospital lowers the cost and the risk the patient will pick up an infection.

Plummer's cancer was at an early stage. If it had been more advanced and the risk of spread to the lymph nodes had been greater, it would not have been the right approach, experts say.

-- The Canadian Press

Republished from the Winnipeg Free Press print edition October 16, 2012 A2

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