(Photography by Kevin Van Paassen)
In September 2019, Alice Lam was leading a busy life: reading, cooking, meditating, working on her photography skills and doing small projects around her Scarborough, Ont., home. Despite having Stage 4 breast cancer (meaning that the cancer has metastasized, or spread to other parts of the body), the 55-year-old was determined to live life to the fullest.
But that changed when, seemingly overnight, Alice went from working out at the gym to barely being able to walk. Weakness in her legs, back pain and numbness immobilized her. She found it impossible to even use the washroom.
“It happened so fast,” she says. “It didn’t take a month. It just took a few days.”
Believing it was a nerve issue, Alice’s family rushed her to a downtown Toronto hospital, where she received devastating news: a metastatic tumour had grown larger despite chemotherapy and was pushing on her spine – an exceptionally challenging area to treat. There was nothing they could do for her. Paralysis would be her new normal.
Fortunately, one of the doctors offered to get Alice a second opinion. He sent an e-mail with her MRI results and physician’s report to Dr. Jeremie Larouche, an orthopaedic surgeon at Sunnybrook. It was 3 a.m., and Alice was sent home.
She didn’t have to wait long. Within nine hours of receiving the e-mail, Dr. Larouche had not only read about Alice’s condition, but he had also coordinated a detailed treatment plan. She would have surgery the very next day. Alice says she was amazed by the speed of Dr. Larouche’s response.
“I’m a fast person, but he acts even faster!” she says, laughing.
The innovative surgery Alice was going to receive wasn’t meant to remove the entire tumour, however. Dr. Larouche would be performing “separation surgery,” a minimally invasive procedure that shears away a portion of the tumour from the spinal cord, potentially reducing recovery time, length of stay at the hospital and surgical complications.
“To see what we can offer [these patients] in their last years of life – it’s an unbelievably, intrinsically rewarding type of surgery.”
– Dr. Jeremie Larouche, orthopaedic surgeon at Sunnybrook
The surgery creates a two-to-four millimetre margin between the tumour and the spinal cord. That extra space is needed in order to protect the spinal cord from the second part of the procedure – radiation.
“Traditional radiation is limited in terms of the duration of benefit, so in select patients a new technique known as stereotactic body radiotherapy, or SBRT, is increasingly offered,” Dr. Larouche explains. “SBRT is an intense and targeted form of high-dose radiation, and for the spine, it is optimally delivered if there is some separation between the spinal cord and the cancer.”
Orthopaedic surgeon Dr. Jeremie Larouche performs separation surgery on a patient with metastatic spinal disease. (Photography by Doug Nicholson)
With SBRT, radiation therapists and oncologists pinpoint the cancer’s exact location and shape using sophisticated, 3D-imaging technology. Once mapped, numerous radiation beams are focused at the tumour from hundreds of different angles simultaneously.
While this combination of minimally invasive, debulking surgery and SBRT does not cure cancer, it does give an 80 per cent to 90 per cent chance that the tumour will stop growing and be controlled for the rest of the patient’s life. Furthermore, the combination of neurologic recovery and tumour control with SBRT can lead to better quality of life by maintaining mobility and decreasing pain.
Rather than spending their last few months bedridden with spinal-cord compression and nerve pain, many people are now able to walk, garden and even leave the house to visit friends.
But the technique has also required that surgeons and radiation oncologists at Sunnybrook develop a new mindset about how to best care for palliative cancer patients. In the past – and in many cancer centres to this day, as Alice discovered – Stage 4 patients have been considered too high risk for spinal surgery. Because of this perceived risk, and the fact that traditional radiation generally isn’t as effective when the disease is compressing the spinal cord for Stage 4 patients, many doctors wouldn’t consider surgical intervention an option.
“But now we have new tools and new techniques,” explains Dr. Larouche, who, along with Sunnybrook radiation oncologist Dr. Arjun Sahgal, has been leading the way for separation surgery, not just at Sunnybrook, but also in North America.
“Really, what I’m trying to bring is a change in mentality and attitude about surgical skills, such as less-invasive or minimally invasive surgery, to achieve our goals,” he says.
Dr. Sahgal, a recognized international leader who pioneered spine SBRT for Canada, adds that SBRT technology is often a very good “next step” for the right candidates, because it delivers extremely precise, very intense radiation doses aimed to destroy cancer cells while minimizing damage to healthy tissue.
“As early adopters, we and a few other centres globally have really promoted the idea that if you’re going to put somebody through a major operation, then why would we not follow it up with an equally aggressive radiation treatment?” Dr. Sahgal says.
In addition, rather than having to undergo five or even 10 radiation sessions, SBRT for the spine often requires only two sessions. For palliative patients, fewer trips to the hospital are a boon.
Dr. Sahgal notes that Sunnybrook leads the field internationally with respect to SBRT technique and outcomes, and he and his colleagues have published several studies in medical journals and led several clinical trials in this domain.
“In fact, we teach radiation oncologists and surgeons globally how to perform spine SBRT safely,” he says.
Alice says she’s incredibly grateful for Dr. Larouche and Dr. Sahgal’s commitment to helping patients like her get back on their feet again – literally.
Orthopaedic surgeon Dr. Tan Chen (foreground left) and Dr. Larouche (foreground right) during separation surgery. (Photography by Doug Nicholson)
One month after surgery, Alice was able to walk with minimal assistance. Soon after receiving her doses of radiation, she was able to walk quite naturally. That’s a far cry from how immobile she was before undergoing separation surgery and SBRT.
“Alice has just got this spirit. She’s indomitable and she’s done fantastically,” says Dr. Larouche. “This is a hard patient population to work with, because these awe-inspiring people are palliative. But to see what we can offer them in their last years of life – it’s an unbelievably, intrinsically rewarding type of surgery.”
While Alice knows the procedures were not meant to cure her, she says they have given her the next best thing – hope at a time when she felt hopeless.
“I prayed for experienced doctors, a proper diagnosis, and effective and timely treatment,” she says. “And I got all of those from Sunnybrook.”
