M. D. Anderson Cancer Center
Date: October 2008
Duration: 0 / 09:28
In the United States there's about 16,000 people a year that are diagnosed with esophageal cancer and I think that's actually pretty minimal compared to what we have as a worldwide problem, and we're lucky for that; but worldwide this happens in the hundreds of thousands of times.
The type of esophageal cancer we get primarily here in the United States is adenocarcinoma of the esophagus, and that's typically caused by reflux disease. We think that it's reflux associated, at least 50 percent of the time if not higher. But those people who have heartburn and who have smoked throughout their lives, those are people who are at the highest risk to go on to get esophageal cancer. Now people who have heartburn may go on to get changes within the esophageal lining. Those changes is the equivalent to me taking the inside of your room and instead of it being paint on the inside of the room, I'm gonna line the inside of your room with velvet. So from the esophagus analogy, I'm gonna take the lining that's on the inside of your esophagus and change it from the normal esophageal lining to change it to this velvet lining, this Barrett's esophagus, which is a pre-cancerous change. You can present with symptoms that when the disease is a little further along, and we typically will see difficulty with swallowing. It's difficult for you to swallow because the tumor is starting to obstruct the esophagus and it's grown into the esophagus, so neither food or liquids won't go by. You may find that you're regurgitating food or just feels like it won't go down. Some patients complain that they're losing weight, and despite the fact that they're eating and they have an appetite, they can't keep any weight on them. So unexplained weight loss is always a signal that we want to have evaluated by our doctors. So problems with swallowing, pain with swallowing, atypical chest pain that's not heart related or not cardiac related, needs to be looked at in terms of the esophagus, and then weight loss are some of the other findings.
I think that people who have had reflux disease, who have had heartburn for longer than 10 years, should consider getting an endoscopy. I think anybody who has heartburn that is not relieved by their medication should consider getting an endoscopy. I think anybody who has had reflux disease for a long period of time and had heartburn for a long period of time, and suddenly it seems like that heartburn is gone away for no particular reason; they should go get an endoscopy because that reflects the lining changing from that normal esophageal lining to that velvet lining, which is not sensitive to the reflux anymore. So many patients come in and tell me, yeah I had heartburn about 15 years ago, I had it most of my life, but then it went away and I haven't had heartburn for the last 15 years. I can tell them, that's when the lining changed in your esophagus from being the normal lining to this velvet insensitive lining - but that's still the precursor to esophageal cancer.
It depends really on stage, so the first thing that we want to do is to figure out do you have a disease? If you come in, basically most people say I have difficulty swallowing. By the time someone has manifested difficulty in swallowing, it generally means that the tumor has to have obstructed the esophagus to some extent. So at that point we're really talking about a tumor that's locally advanced. And so we start talking about multimodality therapy or radical surgery, or both. In my case, I advocate that patients look into getting chemotherapy and radiation because that can affect the overall outcome of the case, meaning higher chances of a cure. I also advocate radical surgery, in that I remove all the lymph nodes, I remove the esophagus down to negative margins in all directions so that I completely eradicate the esophageal cancer and make sure that the tumor doesn't recur locally. But surgery isn't for everybody. So someone who walks through the door at M. D. Anderson Cancer Center saying number one, I don't think I can handle surgery or I don't think I want chemotherapy or radiation. So all these options are on the table. You can consider radical surgery, you can consider chemotherapy or radiation and surgery, you can consider just chemotherapy and radiation alone as a potential cure; and all these things work in different situations.
We really stress multimodality treatment here at M. D. Anderson. We have the opportunity to be working with the world class medical oncologists, world class radiation oncologists and surgeons, and we all get together to try and come up with a treatment plan. We have an entire team of people who are really taking care of these people, and everybody together puts something into the pot to really create an overall cure, overall increased chance for cure for these patients. When a patient comes into M. D. Anderson and they have a new diagnosis of esophageal cancer, I know that first and foremost that patient wants to get started on therapy, they want to be either in the operating room tomorrow or they want to be started on chemotherapy as of yesterday; and I understand that emotion. But what I spend the most time talking to patients about is, it took years for this esophageal cancer to grow, it's gonna take us a week or two, maybe even three weeks, to figure out exactly where this tumor is, what it's doing, what the stage is, and to educate you primarily on what it's gonna take to treat this so you can make an informed decision. And so they spend a significant amount of time with me, they spend a significant amount of time with a medical oncologist, with a radiation oncologist. We all get together as a group on Tuesdays where we have a multidisciplinary conference, and we all discuss that case together again and spend even more time reviewing the case and then come up with a recommendation, a treatment recommendation, that's a congealing of all of our opinions. We then take that back to the patient and say, this is what we all have come up with, we think is a reasonable recommendation for you for treatment.
Some of the innovative things that have come out of M. D. Anderson most recently, where we're using proton therapy to treat patients with esophageal cancer. That's something that's not been done anywhere in the country or anywhere in the world prior to doing it now. We think that really is going to affect the patient's overall side effects, meaning that we think that with proton therapy we can decrease the amount of side effects that you get from treatment. Let's face it - there's no way that we're gonna take someone who's got esophageal cancer, go through all these treatments and have a person that's completely 100 percent the same as they were before; but as you saw in Sue's case, the quality of life is very, very good, excellent, and in some ways better because you're no longer dealing with the spectrum of having cancer. Another way we're dealing with that is we have a minimally invasive program, so for patients who we think are appropriate, have appropriate stage of disease or who have had an appropriate response to chemotherapy and radiation, we'll do a minimally invasive surgery where we don't have to cut ribs or spread the ribs or anything like that. We make small incisions, the recovery is very fast, and that's pleasing to patients. That's going very well. We also have multiple protocols with chemotherapy. So there's the surgery aspect, there's the radiation aspect, and then from the chemotherapy aspect, there's multiple different protocols that we're running which are experiments to try and find out which protocols are the best. And here we run multiple protocols to try and figure out which chemicals really are gonna effect the tumor the most.
At any given time we'll have between 2 and 4 trials going on depending on whether for its resectable or unresectable patients; meaning if it's a patient who qualifies for surgery they may undergo clinical trials for one or two different trials that we have going. If they don't qualify for surgery or don't want to have surgery, they may have the opportunity to enter into two other types of trials that we have going currently.
I would say above many things, we consider quality of life one of the most important things. We know for a fact that cancer, as an illness, is something that we're going to be able to beat frequently or we're very honored to be a part of that process at any point of the game. But we also know that it's not always a process that we're gonna beat but we can help extend people's lives. We can also improve on the quality of life while they're going through the process. So many people have the concept that if they're gonna take chemotherapy or they're gonna take radiation, that if it's not gonna cure them then it's not worth the therapy, that it's gonna make them sicker rather than better. And I would argue, and I do with patients who have that opinion, that actually by treating you, you're gonna feel better and have a better quality of life. And so we make a point of asking, how do you feel? What's going on? What's going on with your life? What's going on with your quality of life? And so I give a survey to my patients sent before surgery, after chemotherapy and radiation, after surgery, etc, to find out where they are in terms of their quality of life. It's very important to us.
What it comes down to, is you can go to a lot of different centers in the world or in my case, the whole world's not open to me but the country is, and I could work at one place and I may have great surgical support or I may have great medical support, I may have great operating room support, but if you want to go to a center where they are supporting the disease process all the way around and the doctors who are working on it, the healthcare workers that are working on it, anybody who's involved in the team - which we have a very big team - M. D. Anderson supports that. And it's like we've all decided that we're gonna agree to meet in Houston and take care of esophageal cancer. And that's true for any cancer that we treat at M. D. Anderson. We've agreed to get together, all the specialists who treat a certain disease, have agreed to get together here, we're assembled under one roof, and we've established a program here; and that's why we're here - because the patients know it, so the patients are gonna come here. The doctors agree to come here, we all get together and we have a great program.
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