One tough mother back on the road after colon cancer surgery

The case of Nicole Fowler, running again after two years of treatment, illustrates why colon cancer screening starts at age 45
March 26th, 2019
The Fowler family, taken the week before Nicole started chemotherapy.
The Fowler family, taken the week before Nicole started chemotherapy. Photo courtesy of Bridget Haber.

Nicole Fowler didn’t go through six rounds of chemotherapy, a complex six-hour HIPEC surgery involving a pelvis-to-stern incision and a painstaking abdominal cleanout, another six rounds of chemotherapy, and months of slow recovery to save your life.

She did it so she can be there for her four kids – the oldest now 16, the youngest 12 – and her husband John. But perhaps her story, can nudge you into saving your own life, for your own loved ones, at a far lower cost.

Nickie, as her friends call her, was 44 years old and in phenomenal shape – she had run half-marathons in sub-8-minute splits and had recently finished a full marathon fast enough to qualify for Boston, a high bar. She was preparing for her first Ironman triathlon. Then, during a party at a neighbor’s house during the 2016 Nebraska-Oregon football game, she got into bean dip for the first time in years. The nasty stomachache started dull but evolved into what she described as “labor-like pain,” which even the non-childbearing among us recognize as a synonym for “excruciating.”

She felt a bit better the next day, enough so that John joked, “You shouldn’t have been eating bean dip. Leave that to the professionals.” The day after that, Nickie seemingly on the mend, John was off to Montana on a business trip. But by Tuesday, the pain turned into a fever. Nickie ended up in an emergency room, and, soon, an operating room.

It hadn’t been the bean dip. Her appendix had ruptured.

Why her appendix had ruptured would take more than a year to piece together. In September 2017, she noticed “something is growing in my abdomen, and I knew I wasn’t pregnant.” A surgery on Oct. 2 at a community hospital started under the assumption that they would remove a benign ovarian tumor; it ended with much more extensive excisions and a dire diagnosis: advanced abdominal cancer.

‘Let’s just get it done’

As best as doctors could tell, the ruptured appendix had happened because of cancer in the cecum – a cul-de-sac near the start of the colon. The appendix dangles off the outside of the cecum, and damage from the cancer probably triggered the appendicitis.

John broke the news to his kids. Evan, the oldest, didn’t say a word. Thomas asked if she was going to be OK. Sophie cried. William, who has autism, asked if she was going to die. No, John said. But it was going to be a battle.

Nicole and John Fowler outside their home in Centennial in late February.
Nicole and John Fowler outside their home in Centennial in late February.

The battle would be waged at UCHealth University of Colorado Hospital at the Anschutz Medical Campus (UCH). The first step was her file coming before a team of gastrointestinal oncologists, radiologists, radiation oncologists, pathologists and others participating in the hospital’s Colorectal and HIPEC Multidisciplinary Clinic, where a diverse group of specialists establishes a care path for tough cases such as Nickie’s. The team understood the cancer to be slow-growing and to not have spread beyond the abdominal cavity or to the liver or lymph nodes. HIPEC surgery – for hyperthermic intraperitoneal chemotherapy – would come into play. But the invasive, hours-long operation would have to wait.

University of Colorado School of Medicine GI oncologist Dr. S. Lindsey Davis and surgical oncologist Dr. Martin McCarter met with the Fowlers to walk them through a plan for the weeks and months to come. Nickie would start with six rounds of FOLFOX chemotherapy, after which McCarter would lead the HIPEC surgery. Once Nickie had recovered from the surgery, another six rounds of chemotherapy would follow. It was a lot to fathom, but Nickie was uncowed.

“I was heads-down, let’s just get it done,” she said.

50 to 45

Fowler was young for colon cancer – just 46. But cases of colon cancer among young people nationally have been on the rise, and Davis and McCarter had recently been among several UCHealth physicians who had co-authored a paper concluding that, while colon cancer rates in Colorado had fallen among those over 50, they had risen among those under 50.

Nicole Fowler during the 2016 Santa Rosa Marathon. Her time was fast enough to qualify for the Boston Marathon.
Nicole Fowler during the 2016 Santa Rosa Marathon. Her time was fast enough to qualify for the Boston Marathon.

What’s causing that increase among younger people remains unknown, Davis said, though processed and fast foods have come under suspicion.

“Studies are really hard to do because there are so many different variables,” she said.

The trend has led the American Cancer Society to lower the age it recommends for an initial colon cancer screening from 50 to 45 – though insurers may or may not cover until age 50, Davis said. (The U.S. Preventative Task Force guidelines, which are being updated, have so far stuck with the age-50 recommendation.)

On Friday, Nov. 3, 2017, Nickie started chemotherapy via a port placed in her chest. Two of the drugs trickled in the outpatient infusion center at the UCHealth Cancer Care – Anschutz Medical Campus; the third, fluorouracil (the second “F” in FOLFOX), would flow through a slow-drip pump over the weekend. John described the pump’s fashionability in one of many CarePages posts:

“…she gets to carry [it] around in….wait for it…. A FANNY PACK. Yes…the fanny pack is back. Words fail me to describe how cool she looks. I’ve started scouring the internet for leg warmers, roller skates, and a Sony Walkman.”

Humor is only so effective a salve, alas. Chemotherapy took its toll. It whacked Nickie’s white blood cell count, produced a nausea that took several tries with different drugs to quell, sapped her energy, ushered in neuropathy and, as winter set in, made her terribly sensitive to cold. The sixth chemotherapy round happened in mid-January. Scans afterward showed some reduction of tumor size, but she was far from clear. GI cancers such as hers don’t respond much to standard chemotherapy, which was why HIPEC had been on the table from the moment she came to UCH.

Serious surgery

HIPEC is, as McCarter described it, “a very aggressive operation to try and treat a very difficult disease.” Colorectal cancers and other abdominal cancers, most of which are adenocarcinomas, often spread through the abdomen’s peritoneum, a thin lining that covers and supports abdominal organs. There’s not a lot of blood flow to that lining, which limits the effectiveness of standard intravenous chemotherapy. HIPEC involves the delivery of a hot liquid mitomycin-C chemotherapy – it’s heated to nearly 108 degrees Fahrenheit – directly into the abdominal cavity. But first, the surgeon physically removes as much of the cancer as possible.

More than 40 HIPEC procedures a year are done at UCH, by far the largest volume in the region. McCarter says the majority of them are done by Dr. Steven Ahrendt, director of the CU School of Medicine’s cytoreductive surgery/HIPEC program. McCarter, also experienced with the procedure, performed it on Nickie on Feb. 21, 2018.

HIPEC can routinely last 12 hours; Nickie’s surgery took just half that long, a positive sign. McCarter removed hundreds of tumors and swaths of affected tissue, based both on what he saw and what he felt as he probed with gloved fingers for malignancies as small as a grain of sand. He then sutured Nickie closed so the team could circulate with a special pump the hot chemo fluid through her abdomen for 100 minutes, pressing and swirling her midsection with their hands to better the mixing. They drained the chemotherapy, McCarter tied up the loose ends, and they were done. Now it would be a matter of recovery, watching and waiting.

So far, so good

It was a tough recovery. The pain was severe, even from the perspective of a woman who took no pain meds after C-sections. Her digestive system took months to recover. The Fowlers were navigating rough seas; help from friends, family, their church, John’s CrossFit gym and others kept the ship from foundering. Nickie recovered enough that, by April 20, she could start another six rounds of chemotherapy. It was just as hard as the first time around, although the weather was warmer, at least. Davis, her oncologist, felt for her.

“It’s hard to put someone through that difficult path, but it’s the best chance we have,” Davis said. “Throughout, she was positive and upbeat.”

Scans in June came up clear, as they did in September and December 2018. Chances are, the cancer will return: Dr. Paul Sugarbaker, who pioneered the procedure decades ago, has put the odds of five-year survival for HIPEC patients at 33 percent, and the percentage of those cured at 25 percent. That’s enough for Nickie, who’s started running again and plans to be in the happy minority on both counts.

“Less than 5 percent of the population probably runs sub-eight half marathons,” she said. “And there’s a mental component that’s been pretty powerful.”

She and John described their care at UCHealth as “awesome.” But it’s the sort of care they wouldn’t wish upon anyone. Which brings us back to you.

Are you pushing – or over – 50?

Have you had a colonoscopy or other colorectal cancer screening?

About the author

Since 2008, Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado. He was a 2007-2008 Ted Scripps Fellowship recipient in Environmental Journalism at CU.

His latest book, "The Laser That’s Changing the World," tells the story of the inventors and innovators who saw, and ultimately realized, the potential of lidar to help solve problems ranging from smokestack-pollution detection, ice-sheet mapping, disaster recovery, and, ultimately, autonomous-vehicle guidance, among many other uses. His first book, "From Jars to the Stars," recounts how Ball Aerospace evolved from an Indiana jar company - and a group of students in a University of Colorado basement - to an organization that managed to blast a sizable crater in the comet 9P/Tempel 1. "Jars" won the Colorado Book Award for History in 2012.

Todd graduated with a business degree from the University of Michigan, where he played soccer, and with a master’s degree from the Fletcher School of Law and Diplomacy at Tufts University. Before becoming a journalist at the turn of the millennium, he was an IT and strategy consultant. He once spoke fluent Japanese and still speaks fluent German.

When not writing, he spends time with teenage daughters and wife Carol, plays soccer, and allows himself to be bullied by a puggle he outweighs by a factor of seven.