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Pre-gastric bypass surgery test uncovers woman's cancer

Pre-gastric bypass surgery test uncovers woman's cancer
Rachel Sandridge walks on her treadmill at home. When she went in for pre-surgery exams for gastric bypass weight loss surgery, they found she had stomach cancer, a usually deadly disease because it's not found early. Doctors used the bypass surgery to treat her. (Algerina Perna, Baltimore Sun)

In the past five months, the pain has receded in Rachel Sandridge's back. Her legs aren't so sore and she has a lot more energy.

Her clothes have dropped by 10 sizes, and her life expectancy has likely jumped by years.

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Sandridge, a 30-year-old who lives in Dundalk, has battled her weight all her life and finally built up the courage to seek gastric bypass, a common type of bariatric surgery that promotes long-term weight loss by reducing the size of the stomach.

It's known to stave off or even reverse disorders such as diabetes and heart disease. But it was a pre-operative procedure not routinely performed on bariatric patients that likely saved Sandridge's life, because it found she had stomach cancer.

"If I'd not gone through with the [weight loss] surgery when I did, things would be 100 percent different," she said. "My cancer would have probably spread and it would have been too late to have had anything done about it."

Sandridge had an endoscopy, in which a flexible tube and camera are passed through the digestive tract to identify problems. It is one of a battery of mandatory tests and classes at MedStar Franklin Square Medical Center before surgery, which requires a lifelong change in eating habits.

Various studies show benefits to some patients undergoing an endoscopy before bariatric surgery, though finding stomach cancer, or cancer in general, is uncommon. The procedure can find infections, ulcers, hernias and other issues, which can improve the way surgery is done and prevent post-surgery complications.

But most U.S. centers don't perform them unless there are symptoms or a history of disease because, like other screening procedures, the studies don't conclude they are universally necessary given the risks and costs — there are more than 250,000 bariatric surgeries annually, according to the U.S. Centers for Disease Control and Prevention.

Franklin Square performs about 210 bariatric procedures a year, and each patient gets an endoscopy, according to Dr. A. Steven Fleisher, a gastroenterologist who is part of the hospital's bariatric surgery team.

He considered Sandridge's case something of a "vindication" of the practice.

Stomach cancer is not among the most diagnosed cancers, with fewer than 25,000 cases annually, but one that is often fatal because it's not discovered in early stages. The American Cancer Society reports that the five-year survival rate is about 29 percent, though it rises to 71 percent when the disease is caught before it spreads.

Sandridge's father died of the disease in 2012, but she was considered young for such a diagnosis.

During her endoscopy, Fleisher found gastritis, an inflammation of the stomach lining, and took a biopsy to check for infection or another problem. He did not suspect cancer, though over the past five years with the program he has occasionally found other issues.

A little to the left or right and the biopsy would likely have missed the disease, he said.

When lab results found cancer on a Friday last summer, he left a message for Sandridge to come to his office on Monday. But Sandridge suspected why he was calling and pressed the doctor on the phone to give her the news, which was particularly hard for her family, a close-knit bunch who work together at their heating oil business and had recently lived through the death of Sandridge's father.

Fleisher did another endoscopy that used ultrasound technology to hunt for trouble spots. He snipped some tissue, and further testing revealed he had removed all of the cancer. Doctors decided to proceed with the gastric bypass, which reduced Sandridge's stomach by about 95 percent, as further treatment.

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She is now cancer-free and has dropped her weight from about 430 pounds to about 288, including about 50 pounds before her gastric bypass. She now eats five small meals a day and is a regular gym goer. She plans to start running in hopes of getting below 200 pounds.

"She's a poster child for why we take a look at patients prior to bariatric surgery," said Fleisher.

"Once in a while a case comes along that reinforces that it's not a bad idea to take a look because we find something that necessitates a different approach," he said. "This is a dreaded disease we don't like to see in a young person, but we nevertheless had an opportunity to diagnose it in an early stage and now she has her whole life a head of her."

Still most U.S. centers don't perform routine endoscopy prior to bariatric surgery. The Johns Hopkins Center for Bariatric Surgery, which has about 350 cases a year, selectively performs them when patients have ulcer disease or severe reflux, for example.

The Penn Metabolic & Bariatric Surgery Program, which performs more than 700 procedures a year in the Philadelphia area, also does not perform an endoscopy on each patient, but Dr. Noel Williams, the center's director, said, "I would not be against endoscopy as a first-line investigation."

Groups of specialists also don't recommend their routine use, including the American Society for Metabolic and Bariatric Surgery or the American Society for Gastrointestinal Endoscopy.

The routine screening is more common in Asia, where stomach cancer is more prevalent, said Dr. Steven A. Edmundowicz, chief of endoscopy at Washington University School of Medicine and a spokesman for the American Society for Gastrointestinal Endoscopy.

But in the United States, he said, there is less such cancer and more of a debate. The largest studies show no more than a 9 percent chance of finding anything through routine endoscopy before bariatric surgery, and those findings are usually benign, including hiatal hernias or esophagitis, or inflammation of the esophagus, he said.

"Because we would have to endoscope so many patients to find a single case of gastric cancer, screening is currently not recommended," said Edmundowicz.

Sandridge considers herself an upbeat and happy person, and now she also considers herself a lucky one. She picked the right time for surgery, when her cancer was early, and her doctor checked the right spot. She also picked a hospital and bariatric team that made a decision to screen its patients with endoscopy.

She said, "It couldn't have worked out more wonderfully."

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