Rectal cancer treatment without surgery

June 17th, 2020

Jeff Armentrout is a first, a designation he never sought and in many ways he wishes he never had, but his cancer put him in that position.

In August 2016 Armentrout, then 39, was in the midst of life as a law enforcement officer in northern Colorado when he began experiencing fatigue and saw blood in his stool. The tiredness was a puzzle to a guy who moved from high school sports in his native Omaha to a college career as an offensive lineman for the University of South Dakota’s football team and a discus thrower with the school’s track-and-field unit. The physician he saw attributed the bloody stools to hemorrhoids – perhaps the result of the mountain biking, running and lifting he did regularly.

The summer after finishing his rectal cancer treatment without surgery, Jeff enjoyed a trip to the beach in California. Photo courtesy of Jeff Armentrout.
The summer after finishing his rectal cancer treatment without surgery, Jeff enjoyed a trip to the beach in California. Photo courtesy of Jeff Armentrout.

The problems didn’t clear up, so in December 2016 Armentrout got a colonoscopy, a key screen for precancerous and cancerous polyps in the intestinal tract. The procedure revealed suspicious lesions, and the news worsened when a biopsy confirmed that Armentrout had rectal cancer: tumors in the lowest section of the large intestine. Some 43,000 new cases of the disease are diagnosed each year in the United States, about a third of the 130,000 colorectal cancer cases annually diagnosed in the country.

Armentrout’s gastroenterologist told him that he needed surgery to remove the tumors and handed him a list of general surgeons with the advice to have the procedure done before Christmas, a couple of weeks away.

The situation was urgent. Armentrout’s cancer was Stage III B, meaning it had spread to nearby lymph nodes, though not yet to other organs. Shortly after his tests, he passed a large amount of blood and had to go to the emergency department. Still, after doing his own research, he decided to seek a second opinion about the best course of treatment. That led him to UCHealth University of Colorado Hospital on the Anschutz Medical Campus and put him on the road to becoming a first in UCHealth’s innovative treatment of colorectal cancer.

A new consideration: rectal cancer treatment without surgery

Jeff Armentrout (left) with his younger brother Jeremy. Jeff credits his family, as well as friends and faith, for helping him through his battle with rectal cancer, which included treatment without surgery. Photo courtesy of Jeff Armentrout.
Jeff Armentrout (left) with his younger brother Jeremy. Jeff credits his family, as well as friends and faith, for helping him through his battle with rectal cancer, which included treatment without surgery. Photo courtesy of Jeff Armentrout.

At UCH, Armentrout met with a multidisciplinary team, including a medical and a radiation oncologist and a surgeon, who considered his possible paths forward. After reviewing his case, the care team offered a treatment approach called neoadjuvant therapy that involves doing complete regimens of chemotherapy and radiation in the hopes of shrinking tumors as much as possible before surgery, rather than adding rounds of chemo after surgery, said Dr. Christopher Lieu, associate professor of Medicine-Medical Oncology and director of the Gastrointestinal Medical Oncology Program at the University of Colorado School of Medicine. Lieu was among those who met with Armentrout.

The approach also offers a new measure of hope for a small group of patients who achieve a “complete clinical response” – eradication of the cancer cells from the rectum – after chemo and radiation, Lieu said. These patients might even be able to recover without surgery, an idea pioneered by a group of surgeons in São Paulo, Brazil in the early 2000s. Memorial Sloan Kettering Cancer Center in New York successfully tested the nonsurgical strategy, dubbed “selective nonoperative management,” with studies that began in 2014, he added.

For this select group (about 30% of patients), the chances of remaining cancer-free for the rest of their lives are about 70%, said Dr. Jon Vogel, professor of Surgery-GI, Endocrine and Tumor Surgery and head of the Colorectal Surgery Section at the CU School of Medicine, who also met with Armentrout. In addition, selective nonoperative management allows some patients to avoid a permanent colostomy – an opening in the abdomen attached to the top of the colon to allow waste to leave the body for capture in a bag, he added.

Surgical challenges for rectal cancer

Rectal cancer surgery presents a number of difficulties, Vogel explained. He noted that the rectum is confined to a narrow space, surrounded by blood vessels, muscles and nerves.

“It’s a particularly challenging environment to work in because of the anatomical restrictions,” he said. Even a surgery that goes well can weaken nerves and muscles in the bowel already injured by chemo, radiation and the cancer itself, he added. In most cases, patients can recover with a temporary opening (ostomy) for waste to evacuate, but that means waiting for the bowel to heal and then a second surgery to close the opening.

There are other surgical risks, Vogel said, including nerve damage that may lead to sexual and/or urinary dysfunction, Vogel said. “There is just a lot of baggage that comes with rectal surgery.”

Jeff during one of his chemotherapy treatments in Fort Collins in 2017. Photo courtesy of Jeff Armentrout
Jeff during one of his chemotherapy treatments in Fort Collins in 2017. Photo courtesy of Jeff Armentrout

But Vogel stressed that the nonsurgical option, even for those who qualify, is not a slam dunk. “Our concern is that we could be undertreating the cancer,” he said. He noted that there is a roughly 20% chance that the cancer will regrow in the rectum and require potentially more difficult surgery than the one the patient sought to avoid. If the cancer regrows, it may also spread to other areas of the body, Vogel said.

Groundbreaking choice of neoadjuvant therapy

When Armentrout met with Lieu and his colleagues in December 2016, UCH had not tested the nonsurgical approach on a patient with colorectal cancer, though the hospital had adopted the neoadjuvant therapy strategy in 2015 with the arrival of radiation oncologist Dr. Karyn Goodman, who brought it with her from Memorial Sloan Kettering, Lieu said.

With no guarantees other than the promise of constant support from his providers, Armentrout chose neoadjuvant therapy and began his chemotherapy on Jan. 2, 2017. He traveled only a few blocks from his home to get it, at UCHealth Cancer Care and Hematology Clinic – Harmony Campus in Fort Collins, under the care of oncologist Dr. Lynn Mathew.

The trip was short, but the chemo road was rocky. During the second treatment, Armentrout said his heart rate “went through the roof,” to about 180 beats per minute. Lieu told him if that happened again, they’d have to stop the treatment and go to surgery. Mathew referred him for acupuncture treatments, which helped to ease his anxiety. His mother and younger brother, Jeremy, came in from Nebraska to ease him through the ordeal with companionship and home-cooked meals. His faith also helped to carry him through the disease and beyond.

Dr. Christopher Lieu
Dr. Christopher Lieu

“The cancer was a wake-up call for me spiritually to rebuild my relationship with Jesus and God,” Armentrout said. The reawakening “re-centered” him and helped him to focus on taking care of himself and doing the things that were in his power to fight the disease. Meanwhile, he worked light- and part-time duty at his job, which offered a welcome distraction from the challenges of treatment.

Passing the first test for rectal cancer treatment without surgery

Armentrout completed eight rounds of chemotherapy and 28 radiation treatments, also at the Harmony Campus clinic, in June 2017. He was still scheduled for surgery that August, but he learned through a support group that Memorial Sloan Kettering had successfully treated rectal cancer patients without surgery. Vogel did not rule out surgery, but he considered that Memorial Sloan Kettering’s support of the option “the Good Housekeeping Seal of Approval,” if tests there verified that Armentrout had achieved the coveted complete clinical response to his treatments.

At Memorial Sloan Kettering, Armentrout got an MRI and a flexible sigmoidoscopy – a thin tube fitted with a camera that allows providers to see inside the lower intestine. The images showed only a thin white scar. The faint image indicated Armentrout was free from cancer, and he became UCH’s first selective nonoperative management colorectal cancer patient. But the emphasis was on “management.” Armentrout and the patients who have followed him require close scrutiny by providers.

Treatment for rectal cancer without surgery required strict surveillance

Returning to Colorado, Armentrout began a “very strict surveillance period,” as Lieu put it. That meant meeting with all his providers every three months for physical exams, blood work, imaging tests and, if necessary, additional scopes of his intestines.

“We keep a close eye on all these patients to make sure the cancer has not come back,” Lieu said. “If it does, we can pounce on it.”

That’s not a theoretical fear, he added. “In a study of patients receiving non-operative management, the data from UCHealth is similar to other institutions in that about 20 percent of patients saw their cancer return locally,” he said.

Dr. Jon Vogel
Dr. Jon Vogel

Happily, Armentrout is not in that group. In December 2019, he met with Vogel, who smilingly introduced him to colleagues as “Patient Number One,” a pioneer of a new strategy for treating selected rectal cancer patients. As of this June, Armentrout has been cancer-free for three years, a key milestone because in a majority of cases, cancer recurs within that period, Vogel said. He now makes surveillance visits every six months.

Armentrout’s battle continues, however. His rectal cancer treatment without surgery left him with bladder and nerve pain, occasional incontinence and sexual dysfunction. He prefers, though, to focus on the things he values most, which he sums up as “family, faith and friends.” A return to full-time work is also on the horizon, along with many more days of hiking, biking and fishing.

At the dawn of 2017, Jeff Armentrout thought his days might be numbered. Three-and-a-half years later, he thinks about the possibilities that lie ahead. “Hopefully someday I’ll settle down again and have a family,” he said.

As for the multidisciplinary team at UCHealth, Armentrout is also plainspoken. “They saved my life,” he said. “Coming to them was a blessing.”

 

 

About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.