Scott Webb (Host): Dr. Mary Maish is back on the podcast today. And today, we're discussing esophageal cancer, who's at risk symptoms, treatment options, and so much more. Dr. Maish is a thoracic and foregut surgeon, board-certified by the American Board of Surgery and the American Board of Thoracic Surgery and an independent provider who chooses to practice at Franciscan Health.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Dr. Maish, it's nice to have you back again. Today, we're talking esophageal cancer and what folks need to know. And you're the right person to have here, the right expert to book for this one. So, let's start with the basics. What is the esophagus exactly and what's its role in the body?

Dr. Mary Maish: The esophagus is a beautiful mobile tube that extends in the back actually, just right in front of your spine from the back of your throat all the way down to your stomach. It is made out of muscle, and it's like a snake. It has this ability to squeeze in what we call the peristaltic nature, which is from top to bottom, to squeeze food and liquids from the back of our mouth all the way down into our stomach.

Host: Yeah, it's pretty amazing. And, Doctor, I've read that esophageal cancer doesn't often have symptoms early on, but is there anything folks could be aware of, like something they're feeling or experiencing that might tip them off?

Dr. Mary Maish: It is true that, sadly, esophageal cancer can be fairly advanced before people get any symptoms, and that's just because the esophagus is really pliable. It's really able to move around and kind of stretch when something's growing inside of it. So, you can get pretty far along before you start to have any symptoms.

And the most common symptom is going to be difficulty swallowing. And might be kind of subtle at first, where you might just kind of notice here and there a little bit of dry food sticking and you think, "Oh, a glass of water will wash everything down." But over time, it will progress to the point where really swallowing anything is going to be difficult. If you let it go too far, even just swallowing a glass of water, it'll take time and very small sips before you're able to get even just a glass of water down. But it generally just starts with these vague, indescript feelings of just having something kind of getting stuck in the bottom or the mid part of your esophagus.

Host: Yeah. Wondering who's at the highest risk for esophageal cancer? Maybe what advice you'd give to patients to reduce the risk of developing this cancer. I'm assuming usually number one is always just quit smoking. Just about every podcast I do with Franciscan Health, no expert ever says, you know, "It's fine if you're smoking." Let's just kind of go through this, like, who's at the highest risk?

Dr. Mary Maish: Yes. Smoking probably contributes. However, there's been no direct causality between smoking and esophageal cancer. Chewing tobacco can cause cancer of the esophagus at the top of the esophagus, or what we call the proximal esophagus, but again, is limited to just sort of the top of the esophagus.

By far, the most common reason why someone has esophageal cancer is because they've had ongoing, longstanding reflux disease. So, just heartburn that has gone unattended or even heartburn that has been attended to just by being given medications, you know, a PPI or like Zantac or Prilosec, one of these kinds of medicines which take away the pain of the heartburn, but do not take away the problem, so the regurgitation or that fluid coming back up into the esophagus continues. And that chronic spillage of caustic material going up and down in your esophagus, we believe to be one of the more common reasons for why esophageal cancer can occur.

There are some familial links as well. So, there are patients who have a genetic-- maybe passed on through the family, maybe not-- but a genetic predisposition to have a pre-cancerous condition called Barrett's Esophagus, which is a whole podcast in and of itself. Barrett's esophagus is something that gone unattended can lead-- it doesn't always-- but can lead to esophageal cancer. And so, that is a common genetic link that we have seen in a pre-cancerous condition that we have seen commonly in many patients with esophageal cancer.

Host: How do you diagnose esophageal cancer? As you're saying, like we may not really have symptoms, especially early on. So, I'm guessing once folks finally get to you, patient history, looking down there into that snake, so to speak. But how do you diagnose?

Dr. Mary Maish: Usually, if somebody comes to me with difficulty swallowing, the first thing that I'll do is start with an endoscopy. So, this is where you go lightly off to sleep, and you take the camera and you put it into the esophagus, or like you said, into the snake, and we take a look around inside. And when we do that, we are generally able to find it that way, take some biopsies with a forcep and send it to pathology. And pathology comes back and says, "Yep, this is esophageal cancer."

Another common way is to send people for what we call a barium swallow or just a fancy term for swallowing a bunch of barium. And the barium, as it's passing through the esophagus, will have this classic apple core pattern where it looks like someone's taken a couple bites of an apple, as the barium is passing around the esophageal cancer. So, that's another way to diagnose it. But ultimately, we like to get a tissue diagnosis with a biopsy.

Host: Are there different types of esophageal cancer? Not necessarily stages per se, Doctor, but are there different types?

Dr. Mary Maish: There are commonly two major types of esophageal cancer. The most common in the United States is adenocarcinoma. And that's the one that tends to come from the Barrett's esophagus and from reflux. And the other, which is more common worldwide, is squamous cell carcinoma. Squamous cell carcinomas can be caused from a variety of different reasons. Commonly, in some countries where scalding hot tea is tea time pastime, we see high incidences of that. So, some countries in the Middle East, as well as in China.

The other common cause would be exposure to different kinds of chemicals that are in preservatives, so like the nitrosamines that are used to preserve pickled foods. So, somebody who consumes a lot of mustard or pickles, or that pickled diet that we associate with some Japanese cultures. So, these kinds of things tend to cause squamous cell cancers. In the U.S., the adenocarcinomas are really understood to be caused mostly from reflux disease or the exposure of acid or bile acids to the bottom of the esophagus.

Host: Okay. All right. Let's talk treatment options, Doctor, whether it's surgery, chemo, radiation, all the above. What do you do to help folks?

Dr. Mary Maish: We have made a lot of advances in esophageal cancer in just my career time. So, in early stage cancer, so this would be stage I, there are different aspects of stage I cancers. But early stage I cancers can now be removed without surgery. It's done all endoscopically. So, the camera is put into the tube of the esophagus. And using tiny little instruments, we're able to actually remove the cancerous lesions that are still in the very early stages. This is really a great breakthrough because, even 25 years ago, we would just remove the entire esophagus for these super early lesions. So now, we don't need to do that.

Stage I tumors that are just a little bit deeper, some aspects of it can be salvaged by using these techniques, these endoscopic techniques. But generally speaking, if we have a stage I tumor that's gone all the way through into the esophageal wall, then we're going to recommend removing the esophagus itself. And I can talk a little bit about that. But esophageal surgery is about removing the esophagus that includes the tumor. And then, rotating a part of the stomach to replace the part of the esophagus that you've removed. So basically, the stomach mostly looks like a bota bag, and we just make it go from a bota bag into looking like a tube, and we pull that tube to connect it to the esophagus. So, we've just made new part of the snake or a new part of the esophagus. And for stage I and stage II cancers, generally, that's all we recommend is surgery.

Before we take somebody to the operating room or recommend a treatment program, we will complete a staging workup, which is pretty extensive, which includes things like a PET scan, but also what we call an endoscopic ultrasound, which again is another test where we put the camera into the esophagus, and we shoot ultrasound waves in and around the esophagus to see whether or not we have any lymph nodes that are positive. And these lymph nodes are all over the body. And what they do is they kind of collect things that are accumulating in the body that are not supposed to be there, like cancer cells.

And so, if we see that there are lymph nodes that have cancer cells in them from this endoscopic ultrasound or the PET scan, then before going to the operating room, we would recommend going ahead with some chemotherapy, and possibly some radiation as well to the primary tumor just to control the growth of that primary tumor while we're waiting to go to the operating room. So, it really depends on kind of how big the tumor is as to whether or not we would also offer radiation. So, we sort of have on the early stages of esophageal cancer the possibility for not removing the tumor in the surgical suite, but rather in the endoscopic suite, moving into the operating room to remove the esophagus for the more advanced stage Is and early stage IIs. And then, when we get to a later stage II or a stage III, then we're going to be offering chemotherapy and possibly radiation therapy before going to the operating room to remove the esophagus and rotate that stomach up into the area where we can connect the esophagus to the stomach. So, those are the most common treatment modalities for esophageal cancer.

Host: Yeah, pretty amazing. Of course, nobody wants cancer, Doctor. Nobody wants esophageal cancer. But as you say, so many innovations and advancements and options to not just immediately remove the esophagus, which I can't even get my mind around. As you were saying about Barrett's, like I feel like that's an entirely separate podcast. Just how easy you make it sound, even though I'm sure it's not, you know, easy per se. I'll just give you a chance here, Doctor, final thoughts, takeaways, whether it's folks maybe ignoring some symptoms or they're pretty sure they have this and they're dragging their feet, like, what's your best advice?

Dr. Mary Maish: Yeah, I have a couple of pearls to take away. I think the most important of which is that having difficulty swallowing is not normal. Also, having unexpected weight loss or unintended weight loss, which is another symptom, is not normal. So, don't go very long if you're having difficulty swallowing, because it can be esophageal cancer and you wouldn't know it. And it could also be something else, which could be maybe not quite as grave, but also needs to be treated. That is just not a normal thing to have. So if you have it, come in and see an expert right away.

The second thing is that, if you end up having a diagnosis of esophageal cancer, make sure that you find somebody that has a lot of experience in esophageal cancer because there are so many different approaches. This is not a one-size-fits-all disease. And so, many times you find surgeons or hospitals with the treatment groups that just wanted to fit you into the protocol that they are most familiar. But there are many ways to approach this surgery and this cancer. So, it's really critical to find somebody who's got, you know, an expert in the area.

The last thing I would say is esophageal cancer has a really bad rap on the internet. So, try to avoid going to the internet and getting information that is mostly very much outdated. We have a lot of esophageal cancer survivors. And I have so many patients that I am still in contact with that I operated on like more than 20 years ago that are still doing great. It is not a death sentence. It is however a marathon to get through the treatment in order to be able to save your life. But it's well worth it and we have a lot of resources to help any patient get through that in my practice. But there are other people around wherever you're living that would be able to help you as well. But the critical thing really is landing in a place, which will have definite several options for you in terms of treatment options.

Host: Yeah. I love the way you put that pearls, pearls of wisdom from an expert today.

Dr. Mary Maish: Right, right.

Host: Yeah. You know, it's like, yeah, at my age, in my mid-- we'll say-- 50s, if your knee hurts when you wake up in the morning, well, that's to be expected. But if you have trouble swallowing, that's not normal. And you need to speak with your provider. You need to get the referrals you need. You need to ultimately end up with someone like you, you know, who's using the most cutting-edge innovative treatment options to save your life, right?

Dr. Mary Maish: Yeah. I think one of the critical things to remember is that many primary care physicians will sort of downplay this difficulty swallowing in, you know, middle-aged people who commonly get esophageal cancer, because a lot of people get difficulty swallowing for other reasons. And so, they make them wait until it progresses. And so, I've seen so many people in that same bag where they said, "Oh, well, I saw my doctor a year ago and he just told me to try this or to try that." And so, I really want to impress do not ignore that symptom. You need to go in to see an expert, you know, right away.

And I would say the other thing to think about too is that if you have had longstanding reflux and you have never had an endoscopy, you need to get an endoscopy. And if you're due for your colonoscopy, tell your gastroenterologist that you just want an endoscopy added on. They can get that added on through the insurance company. It's not an issue. But at least, if you ever taken any kind of anti-acid medicine for reflux disease, even just one time in your life, you need to have an endoscopy done to make sure that you don't have Barrett's esophagus, a big hiatal hernia, and any other things that are known to be associated with esophageal cancer or can often lead to esophageal cancer if left unattended.

Host: Yeah. Well, it's perfect. I appreciate your time as always. You seem to have all the answers, which is great. And I'm sure that we'll get a chance to speak again in the future. But great advice for patients or prospective patients. We have to ask questions, we have to advocate for ourselves. Maybe sometimes press our primaries a little bit. So, thank you so much.

Dr. Mary Maish: Right. You're welcome.

Host: And to learn more about cancer treatment at Franciscan Health, visit franciscanhealth.org/cancercare. And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.