Papillon X-ray Brachy is making national Press, after its NICE ratification, with its use of low energy X-rays to kill cancer cells; allowing better local control of small rectal cancer tumours and offering patients a real alternative to radical surgery and a permanent stoma.
The bowel cancer operation that means you DON’T need a colostomy bag
- Businesswoman Judith Blount was diagnosed with bowel cancer in 2014 after she noticed blood when she went to the loo
- Doctors told her she’d need her rectum removed and have to wear a colostomy bag for the rest of her life
- Instead, she tried a treatment using low-energy radiotherapy called Papillon, which successfully cured her
A new, less invasive form of radiotherapy is now recommended for bowel cancer by the health watchdog. Judith Blount, 49, a businesswoman from Derbyshire, underwent the treatment…
Just over a year ago, I noticed there was blood in my stools, and went to see my GP. She examined me but didn’t find any swellings which could be cancerous, so prescribed tablets for piles.
But the bleeding continued, so two months later, I had a colonoscopy — in which a flexible tube with a camera on the end is inserted into the back passage — which identified a growth on the wall of my rectum.
The specialist said it was probably a benign growth but referred me for more tests. Two weeks later, those tests showed it was cancer — I was speechless because I had a healthy lifestyle, and no history of cancer in my family.
The cancer was in the rectum, the last section of the large bowel. Although the tumour was small and had not spread, I broke down in tears.
The worst part was being told I would need my entire rectum removed and have to wear a colostomy bag for the rest of my life. I was devastated because it would have such a major impact.
Afterwards, a friend told me he had seen a new treatment on TV called Papillon, which is done without surgery or a bag. I researched it and found it was a type of radiotherapy which kills cancer using low energy X-rays, instead of the high energy X-rays of conventional radiotherapy, which can damage healthy tissue.
The only way to limit the damage is to reduce the dose, which is less effective at killing the cancer. These low-energy X-rays penetrate tissue only to a depth of around 5mm, enough for a small cancer but not enough to damage other tissue.
I discussed Papillon with my consultant, who said it was an option, but emphasised surgery would be needed if the treatment did not destroy all the cancer. I had nothing to lose and there was a chance I’d avoid having a colostomy bag.
I was referred to Jamie Mills at Nottingham University Hospital, who said the success rate of Papillon for my type of cancer was 95 per cent. I gave up work before starting treatment — my first session was in October. I had three sessions and wore paper shorts with a flap at the back and bent over a treatment couch.
I was awake throughout but didn’t feel anything. The doctors applied a local anaesthetic gel and a cream to relax the sphincter muscles to make it easier to insert the applicator, which took a minute and a half to do its work. I felt slightly sore for two days after but had no other side-effects.
After my final Papillon session, I went back to work. The doctors prescribed five weeks of radiotherapy and a twice-daily chemotherapy tablet to kill any cancer that was left.
The rectal cancer has gone and I am no longer passing blood. I have recently done the Derby 10km run and am back travelling as normal. For me, Papillon was the best option and avoided the life-changing effects of a colostomy bag.
Jamie Mills is a consultant clinical oncologist at Nottingham University Hospitals NHS Trust
Bowel cancer is often misdiagnosed as conditions such as IBS or piles because some symptoms are the same.
Lifestyle factors like eating excessive amounts of red or processed meat can increase the risk. Other triggers include a family history and being aged 50 or older, but sometimes the cause is unknown, which was the case with Judith.
The bowel is the part of the digestive system that goes from the stomach to the anus and is divided into the small and large bowels. Bowel cancer is curable if caught early.
Tiny cancers can be removed during a colonoscopy when a thin flexible tube is passed into the bowel and a wire burns off the growth.
For larger growths, the tumour is cut away surgically along with the surrounding section of tissue to ensure no cancer is left behind. Afterwards, the surgeon tries to sew the remaining parts of the bowel together.
However, one in ten patients who have surgery will need a colostomy bag because their cancer is low down the rectum and close to the anus.
Not enough tissue will be left to re-join the bowel so surgeons get around this by making an opening from the rectum to the abdomen for waste to pass through into a bag attached outside.
Many patients find adapting to these bags difficult because you have to cope with leaks, avoid foods that can cause diarrhoea and it can affect their ability to travel.
We have been using a form of radiotherapy known as Papillon, an alternative to surgery which reduces the likelihood of a permanent colostomy bag.
Most hospitals offer only external radiotherapy, an effective treatment for reaching deep-seated tumours but which damages healthy tissue so isn’t always best for small tumours (less than 3cm wide) on the rectum surface.
Papillon — named after the French professor who popularised the technique — uses a metal rod inserted through the rectum until it touches the tumour, where it then delivers low-energy X-rays to kill the cancer cells without damaging normal tissue.
Doctors can deliver a much higher dose of X-ray radiation — the equivalent of five weeks of external radiotherapy in a single Papillon session.
Any surgical procedure carries risks and comes with complications such as bleeding, infection and stroke. So older or unfit patients or those with existing heart conditions wouldn’t be suitable for surgery, and Papillon would be a better option.
Younger rectal cancer patients who don’t like the idea of surgery or colostomy bags can ask to be considered, too.
Like an X-ray, the treatment is painless apart from some discomfort around the rectum where the applicator is inserted, and there is bleeding in around a quarter of cases.
Before inserting the X-ray applicator, we measure the size of the tumour with another tube and select the right size applicator. The applicator is then inserted via the tube until it is in contact with the tumour — it is attached to the X-ray machine via a metal rod which emits low-energy X-rays.
These go through the tube and directly destroy the cancer on the other side, breaking up the DNA in the cells until there is not enough for the cells to repair themselves, so they die. This takes about a minute and a half.
With an early-stage small tumour in the rectal lining, surgery has a 95 per cent cure rate and Papillon between 90 to 95 per cent.
Papillon is less effective for larger cancers or advanced rectal cancers because it cannot penetrate into the deep layers and because larger tumours need more powerful treatment such as surgery.
All types of bowel cancer are treatable with surgery, whereas Papillon is only for the rectum because the straight rod used cannot pass through the bends of the bowel.
The fact that NICE has now recommended its use for patients with early-stage rectal cancer means I expect to see more take-up.
It is a valuable additional treatment and increases the options for patients.
‘Surgery is the gold standard treatment which carries the lowest risk of the cancer returning,’ says Alexandra Stewart, a consultant clinical oncologist at the Royal Surrey County Hospital.
‘If patients are fit for surgery but choose to have Papillon treatment, they must be willing to undergo more intensive surveillance to ensure the cancer has not returned because there is still not enough data on whether it is effective in reducing cancer recurrence.
This means examinations and MRI scans every three months for two years. There is a slightly higher risk of the cancer returning — 10 to 15 per cent with Papillon versus 5 per cent with surgery. If the cancer does return the patient will need standard surgery and then have a colostomy bag fitted.’
Papillon costs £6,000 on the NHS and £9,000 privately.