This case illustrates some important principles in the treatment of rectal cancer.
To learn more, read on!
"Do you recognize me?" she asked quietly. I did…..but I could not quite place her. "I was working at the Laundry in Lam Wah Ee."
Ah! Of course, that was it. Someone who had always smiled at me, but I'm ashamed to say I never knew her name! I left Hospital Lam Wah Ee for Gleneagles in 2012 but have always retained a fond affection for the place.
Madam Tan was a petite lady, in her fifties. She wore a kind face. The motherly sort, I could imagine her in a nice warm comforting home, filled with the aroma of freshly baked cookies. She never had a bad word about anyone. She came with her daughter who had clearly inherited her mother's good looks and demeanour.
This time, there was a hint of worry under that kind smile. She had had difficulty with her bowels for several months. She also had a nagging ache on the left side of her abdomen extending to the back with numbness in the left foot.
A surgeon had told her she likely had piles and back problems and referred her to an Orthopaedic Surgeon who prescribed painkillers.
But she was no better. "I want to pass motion but nothing comes out." Nothing? "Just some blood…"
A red flag!
The sensation of an inability to pass motion despite an urge to do so is called "tenesmus".
This is a specific symptom, often caused by a mass in the rectum. The rectum senses there is something there to push out but being a mass attached to the wall, the rectum is not able to push it out. The rectum reports this to the brain as "constipation".
Placed next to rectal bleeding, another symptom of rectal cancer, the story sounded ominous.
Sure enough, rectal examination revealed a mass.
Colonoscopy confirmed what we already knew, and a CT scan showed some enlarged lymph nodes near the rectal mass but thankfully no spread to the liver and elsewhere.
So, I sat down with her and her family to discuss strategy.
Her cancer was "low" meaning it was situated close to the anus, some 5cm away. The CT scan showed the entire tumour mass to be quite bulky.
I therefore recommended she have radiotherapy and chemotherapy first - a strategy known as Neoadjuvant chemoradiation".
Means giving chemotherapy and radiotherapy before surgery.
The aim is to shrink the tumour down a bit before surgery making it easier to operate to remove the cancer.
It also results in lower risk of recurrence in the pelvis afterwards.
A potential downside is some impairment to healing, which is why most surgeons recommend creating a temporary colostomy to divert away the motions until full healing has occurred (see Colostomy below)
We will then have to go in and remove the cancer, then join the bowel up again. However, as the join would be very close to the anus where there is an increased risk of leakage, we would have to make a temporary colostomy on the right side. This is to divert the bowel motions away from the join near the anus so that, if a leak did occur, it would not be dangerous and should heal by itself.
A colostomy is an artificial anus. The large bowel is brought out through the abdominal wall and an opening created and sutured to the skin.
The bowel motions then come out by themselves straight into a special bag which is placed over the opening.
When the bag is full, it is discarded and replaced with a new one.
Colostomies are much maligned and patients often resist having one. However, it is entirely possible to keep it tidy and comfortable with no smell. Without taking off clothes, no one would know that a person has a colostomy. Obviously, activities like swimming are not encouraged but almost all other daily activities are not hampered by the colostomy.
Most importantly, colostomies are done for the patients safety and can also be life saving if there is a perforation or leak in the large bowel because it diverts away the motions from the problem area.
Colostomies are not painful and can be washed with warm water and soap in the shower, drying gently before placing a new bag over it.
Madam Tan and her daughter were keen to proceed with the operation.
But then she discovered her insurance company would not cover the procedure. Her daughters tried to step up to the mark and offered to withdraw funds from their EPF. However, they could only do so 6 months later.
“Would that be OK?” they asked.
Not a good idea.
With cancer, delays can be costly. While the patient is saving up money for treatment, cancer can progress from something treatable, maybe even curable to a situation where the cancer is advanced, inoperable and one without any good solutions or good outcomes.
So I sent them to see Mr Henry Cheah.
A round bespectacled man with a warm affable manner, he worked in our Accounts Department. I asked if they could maybe defer payment till the EPF came through but go through with the surgery first.
“I’ve got something better than that…” came the reply.
He explained that he knew of some limited funds available to help deserving patients.
I had to write a letter seeking the support of a third party (in this case, the Editor of one of the national newspapers).
I promptly dispatched the letter pleading Madam Tan’s case.
To my amazement, the reply came just a few days later that the application had been approved.
All of it!
Madam Tan and her family were overjoyed, as you might imagine.
And so was I.
We started with radiotherapy.
Her CT scan after radiotherapy showed some shrinkage of the tumour.
We then proceeded to radical surgery, clearing tumour all the way down to the pelvic floor, joining up the bowel and creating a temporary diverting colostomy.
All done with laparoscopic (keyhole) surgery and small scars.
Madam Tan has now completed 12 courses of chemotherapy following her surgery.
She has no sign of recurrent cancer, has just had her colostomy closed and is enjoying a return to normal life.