Small Signs, Big Impact On Life

During the summer of 2021, in the first few weeks after Dunlap Family Outpatient Center opened on the main campus of St. Clair Health, a 45-year-old woman was referred to Mark A. Cedar, D.O., Chief of Gastroenterology and Director of the GI Lab at St. Clair Hospital. “At first I was happy to see someone who met the new screening age criteria (down from 50) for colorectal cancer exams coming in to see me. But there was a reason: a small change in bowel habits. Shannon presented with no weight loss and no abdominal pain and her labs showed iron deficiency anemia—which is not uncommon for a woman her age,” Dr. Cedar says.

An otherwise healthy, young woman, Shannon had no significant medical history, no family history of colon or rectal cancer, and no smoking history—which increases the risk. “I have a great life—a full life—and really just thought there was a little something going on in my stomach. I went through a number of tests with my primary care physician (PCP). We knew something wasn’t right, and that was the most frustrating part, the not knowing,” she says.

“I began Shannon’s colonoscopy and immediately found a large, obstructing mass in the upper rectum, about 5cm in length—which is very large. It was not resectable with the scope, but fortunately I was able to get around it and complete a full colonoscopy,” Dr. Cedar says. “I found many other polyps in her colon, including two large ones that were precancerous, and was able to resect them and remove three additional polyps. So then we had to deal with this rectal mass, and I could tell right away: this is cancer.”

“When I woke up,” Shannon says, “I heard ‘cancer of the rectum’ and actually felt relief— because now I knew what the problem was to solve. My first feeling was, ‘So where do we start?’ I’m a project manager—this is what I do. Dr. Cedar told me right away what he thought would happen and who all would be involved, so I knew right then and there that my story would have a lot of characters. I decided to kind of be the Creative Director of my cancer story.”

CHEMOTHERAPY. RADIATION. RESECTION.
During a long talk with Shannon and her family, Dr. Cedar added one key detail. “With a large tumor like hers, I was suspicious it was metastatic. Depending on the location of the tumor and whether or not it’s metastatic will determine whether the patient receives chemotherapy and radiation prior to Dr. Holekamp performing surgery,” he says.

Shannon quickly experienced one of the greatest benefits of the truly integrated design at Dunlap Family Outpatient Center. “I met with Dr. Holekamp the very next day and he said the very same thing as Dr. Cedar. He also looked me square in the eye and said, ‘You’re used to being successful and I am, too. We’re going to get the best team together and we’re going to push you. Here’s exactly what we’re going to do—and we’re going to crush this cancer together,’ ” she says.

For Scott A. Holekamp, M.D., treating every patient comes down to three things. “We take the tumor out so it doesn’t come back, we minimize the chances that it’s spread, and we put everything back together so your body works correctly again after treatment,” he says.

“And our goal is to communicate quickly and effectively so we can get patients on to the next stage right away. The process may include advanced imaging studies like MRI, PET, or CT, plus consultation with all of the oncologists who become part of your cancer care team here— and they get to work on shrinking your tumor so I can perform surgery. Everyone works together to increase your chances of having a complete response to treatment.”

For Shannon, the next stage following her diagnosis and surgical consult led directly to Christopher R. Marsh, M.D., a medical oncologist and hematologist at the St. Clair Hospital Cancer Center. “We take a team-based approach to everything we do. As doctors, we feel more comfortable that way—and it helps patients feel more confident, too. That level of collaboration brings all of our expertise together for every patient. That way we all know the patients and we’re able to keep their priorities in mind as we evaluate the most effective way to treat their respective cancer,” says Dr. Marsh.

Talking daily. Interacting on a number of mutual patients. And complete accessibility connecting them all the time. With each patient’s goals in the front of their mind, Dr. Marsh leaned right in to the cues he received from Shannon. “She’s a very intelligent and driven woman. She understood what was on the road ahead with her cancer and wanted to take the treatment head-on,” he says.

“There was no trepidation, because there’s been so much transparency in my treatment and that’s awesome,“ says Shannon. “Personalized medicine is why I chose St. Clair—it’s a one-stop shop and that’s what I preach all day long with my company: Why go to multiple places if you can get everything you need from one? It was glaringly apparent that I made the right decision because I had a vacation planned. Dr. Marsh said, ‘You’re going on this vacation—go do your thing, and then we’ll get you right back on your course.’ I really felt like I was being treated like a human being, not just a number—from the beginning, my treatment has been about living my life and curing me of cancer,” Shannon says.

“One thing that’s extremely important for every cancer patient is maintaining quality of life,” Dr. Marsh says. “Work, family, exercise, church—patients tend to do better and be more driven to do better when they’re able to keep doing what they love. And that’s why we strive to integrate our care plans with their activity levels throughout their cancer journey.” With state-of-the-art imaging adding to Dr. Cedar’s expert diagnostic work, Shannon’s rectal cancer was defined as stage 3. Treated initially with chemotherapy, she is now set for a combination of chemotherapy and radiation before surgery. “We know patients have a better response to that—a more complete response—including some cases where the tumor is completely shrunken away,” says Dr. Marsh. “In Shannon’s next phase, the chemotherapy will work as a sensitizing agent—a low dose of chemotherapy that makes her cells more susceptible to radiation, allowing it to be more effective. The two treatment types work together to create synergistic, personalized medicine.”

For Shannon, that level of curated care leads to Felicia E. Snead, M.D., a board-certified radiation oncologist and Chief of Radiation Oncology. “We create her radiation plan via a simulation process. In this simulation, we use imaging of her pelvis to allow us to perform accurate calculations of exactly where the tumor is and also areas of risk like the pelvic lymph nodes. This allows me to spare organs like the bladder, small bowel, and bones that do not require treatment,” Dr. Snead says. “This will also give her reference marks so we can find these areas accurately and safely on a routine basis.”

During the radiation planning process, Dr. Snead uses techniques like Intensity Modulated Radiation Therapy (IMRT) that allow the team to dose-paint the areas where radiation is desired to ensure that the area of disease receives the therapeutic amount while the areas they want to spare get significantly lower doses with respect to their radiation tolerance. “We coordinate everything— Dr. Marsh and I are in lockstep, starting the chemotherapy and radiation together and meeting with her weekly to make sure the treatment is accurate and safe,” Dr. Snead says.

“After she completes her radiation,” says Dr. Cedar, “then Shannon will have surgery with Dr. Holekamp. Then I will repeat her colonoscopy again in one year to make sure she doesn’t develop additional polyps. I stay connected to the patient’s PCP forever—and hopefully, Shannon and others like her never have to see Dr. Holekamp and the rest of the team down the road.”

THE IMPORTANCE OF RECOGNIZING THE SIGNS
“Most importantly, blood in your stool may not just be a hemorrhoid,” says Dr. Holekamp. “If you’re seeing blood, let us take a look and find the cancer that might otherwise be missed. The reason the American Cancer Society’s guidelines are moving to a younger age is because we’re seeing younger patients with cancer. And those guidelines for screening are meant for anyone, even if they don’t have any symptoms—we want to find the polyps before they become cancerous. And I’ll put it more bluntly: you want Dr. Cedar to find them before you need me,” says Dr. Holekamp.

When it comes to definitive testing, data associated with the colonoscopy is overwhelming: 60 percent lower incidence and risk of death compared to some other methods. “For colon and rectal cancer, getting a colonoscopy is the most sensitive and specific way to detect precancerous polyps and colorectal cancer—and yes, I can take out that precancerous polyp before it even becomes cancer. It’s the gold standard colorectal screening test—head and shoulders above the other options,” Dr. Cedar says. And from an oncology perspective, Dr. Snead emphasizes that, “Most cancers are not related to genetics, so everyone should get screening regardless of family history.” Adds Dr. Marsh: “When we screen early, we can catch it early—not only in colorectal, but with breast, prostate, urologic, and more. The earlier we can detect cancer, the better the outcomes are across the board. If we catch it early enough, I may not even have to give a patient chemotherapy at all.”

Shannon Gregg seconds the respective insights of her care team, personifying how St. Clair delivers advanced cancer care close to home. “Timing really is everything. I didn’t even want to go to the dentist during COVID, but with my belly not feeling right…I knew I had to listen to my body. It’s going to tell you the truth every time. You have to be your own advocate, understanding the risk factors, the symptoms, and not putting off early screening. One of the main reasons I’m documenting my cancer journey is to help others who may be on the fence. Cancer doesn’t define me—I have a nine-year-old and it feels like every doctor at St. Clair just gets it: I’m not living for myself—I live for this kid. And getting screened—even when I didn’t necessarily want to and I didn’t have any major symptoms—getting a colonoscopy saved my life.”