Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole and today our discussion focuses on the Esophageal and Gastric Center of Excellence at AHN.

Joining me is Dr. Kirsten Newhams. She's a Board Certified Surgeon with AHN that specializes in esophageal disorders. Dr. Newhams, thank you so much for joining us today. I'd like you to start by telling us how the landscape of esophageal and gastric cancers have changed over the course of your career.

How have you seen the incidence of these cancers and disorders change in recent years? Where in the continuum of diagnostic criteria has HPV or Barrett's been a factor in the trend? Tell us a little bit about what you've seen. 

Kirsten Newhams, MD, MPH: Well, hi, Melanie. Thank you so much for having me on. There's been tremendous evolution in the diagnosis and management of esophageal and gastric cancer, even just in my career. And I think some of it is the treatment algorithms, in particular for esophageal cancer, the addition of immunotherapy, which has just been a game changer for folks at all stages for esophageal cancer.

We're really seeing a lot of promising results from that and AHN in particular is working in a dedicated manner to just see what benefits we can have from immunotherapy and offer that to our patients when appropriate. And then I would say from the treatment perspective, really it's the evolution of minimally invasive platforms. When I first learned esophagectomy, these were very large cases with big incisions, and since then, people have evolved the approach and now we have minimally invasive laparoscopic or robotic approaches with small incisions which is really improving recovery time, diminished pain, and we're seeing improved outcomes across the board.

And so this is true for both esophageal and gastric cancer. And those are some of the more notable changes I've seen. Additionally, at least with gastric cancer, and this is a little bit of a longer evolution, the better treatment of stomach infections with H. pylori has really driven down the incidence of gastric cancer, at least in the United States.

For conditions you mentioned, HPV, there is an association with esophageal cancer, but more importantly, Barrett's esophagus, which is a pre cancerous change of the esophagus induced by acid reflux. The treatment of that has really evolved. Often people with more advanced Barrett's esophagus had to undergo esophagectomy or removal of portions of their esophagus. Now we can treat that endoscopically, small scopes in the throat to treat that and prevent the progression to cancer. 

Host: Well, thank you for that, Dr. Newhams. So where do you stand and we're thinking about these trends and all of those exciting advancements that you've mentioned, where do you stand as to implementing screening? I mean, we have colonoscopy and that is something that is considered gold standard. But what about endoscopy? If it can catch Barrett's in its early stages, tell us a little bit about screening and what you think about that. 

Kirsten Newhams, MD, MPH: That is really where we're a bit behind is there are no good screening standards out, for esophageal cancer or Barrett's esophagitis. Really things like colonoscopy, we have a lot more information on, on who should be undergoing these procedures and when, and we really don't have the data there for esophageal cancer or Barrett's esophagus.

And I think that's really the next avenue of inquiries. What are ways that we can improve catching people earlier in the disease process? Part of it is identifying folks who have reflux disease and managing that appropriately in a longitudinal way. But also, there are people who come in who have esophageal cancer and really didn't have much reflux.

And so that's where we're still scratching our heads.

Host: That's so interesting to me. So let's talk about some of the recent innovations in treatment. And you mentioned endoscopic management of esophageal and gastric cancer in Barrett's specifically. So speak about some of the exciting innovations that you've talked about in treatment. I think you mentioned immunotherapy and endoscopic management. You're a surgeon. Tell us a little bit about some of these treatments. 

Kirsten Newhams, MD, MPH: For Barrett's esophagus, as I mentioned, a change in the lining of the esophagus that's induced by acid reflux. It really can be pretty benign and not progress, but for some people you can have this evolution to abnormal cells called dysplasia, which in time can progress to cancer. And people who develop abnormal cells called dysplasia become a candidate for endoscopic therapy, whether it's something called radiofrequency ablation, which is essentially at the time of an upper endoscopy using a heated probe or balloon to treat that area and cause remission and then have close follow up for that. There are also minimally invasive endoscopic say almost surgical techniques where you can remove the areas of abnormal cells. It's called endoscopic mucosal resection or submucosal dissection, and so these are all done with a thin, flexible scope through the throat, with ongoing follow up after that. And so those are really big changes that have actually evolved in my career. 

Host: Now, as we think of these surgical treatments, as we know, these type of cancers can have devastating effects on quality of life. Tell us about some of the minimally invasive robotic approaches and some of the exciting technology that's out there now.

Kirsten Newhams, MD, MPH: So from a robotic perspective, this has just been a huge evolution, I think for surgeons and for patients. These are small incisions, and there are several different ways to approach the surgery, but ultimately small incisions on the stomach or the chest, sometimes the neck and able to complete the surgery through that means quicker recovery times.

People are back on their feet, diminished pain, less complications and we've seen that, as time has gone on and more and more people have adopted minimally invasive approaches. And so I think from that perspective, we're having good oncologic outcomes, meaning, we're doing a good job of getting the cancer out and then people are recovering faster and quicker.

And then for anyone who needs additional treatment after surgery, they're getting to that treatment quicker. If you have a bigger surgery or a complication and longer recovery time, it's longer before you can get into treatment. And so those are really important considerations when you're looking at the whole patient. 

Host: Well, they certainly are. So along those lines, what does it mean to be a Center of Excellence when we're talking about esophageal and gastric cancers and disorders? Tell us a little bit on, you just mentioned reducing the waiting times after surgery and to get to these suspected or new cancers very quickly. Speak about how a Center of Excellence is really the gold standard for this type of disorders. 

Kirsten Newhams, MD, MPH: We're lucky that the Allegheny Health Network has really focused on this for our patients and, and for people providing care to patients with cancer. And, and really the backbone of it is patient focused care, by providing appropriate educational resources and support. A lot of people when they have this diagnosis, they go online, they look it up, you see really scary information. And so our goal is to provide a support network with options. Because often there are several different pathways that patients can pursue for treatment. And so, not only do we want to give them information, we want to Include them in the decision making process and have our navigators. We have excellent nurse navigators help patients proceed through decision making and treatment and then post treatment care. We're also really keen on making sure that once a diagnosis is made that the patient is appropriately scheduled quickly, with appropriate physicians and teams as needed and then to coordinate that care throughout the whole process and really just be transparent about it so that patients understand their diagnosis and what to expect along the way.

I think one of the nice components that I've seen through AHN are patient advocates themselves; patients who have gone through the process and will reach out to patients who have a new diagnosis of esophageal or gastric cancer and talk to them about their experience. And so those are really some of the foundational elements of a Center of Excellence, as it pertains to oncology care.

And really layered on top of that is research. We really want to progress the field. As I mentioned, we have a lot of information and gaps in our knowledge on who do we screen and how do we catch people earlier in the process. And that's what we're actively working on to develop these trials and answer those questions. 

Host: Really, it's such a comprehensive approach and thank you for mentioning that multidisciplinary team and certainly the role of the patient navigators and the nurse navigators because they play such an important role in helping patients navigate through that scary world when they get those kind of results.

Tell us a little bit about the single port robot when you're talking about reconstructions. Dr. Newhams, I'd like you to speak about surgical planning and reducing those surgical times to improve the recovery. And how do you work with the other physicians involved in that surgical planning for the patient? 

Kirsten Newhams, MD, MPH: We luckily have a very active meeting every week, where we come together, our multidisciplinary tumor board, where we have oncologists, medical oncologists, radiation oncologists, radiologists, nurse navigators, research associates and surgeons, all come together and review, who is this patient, what is their situation and how do we best treat them, keeping in mind their individual needs and factors, and then from there develop a plan.

And I think I've been very lucky to have good communication and support with the different team members so that we can work together collaboratively to provide the best possible individualized plan of care and then honestly from a surgical planning standpoint, working with our radiologists and our medical oncologists, to really figure out, what components do we need to optimize treatment and not everyone has the same pathway and now with the addition of things like immunotherapy, it really is starting to change the landscape in how we treat people and I think we're still early stages in terms of gathering information but so far very promising in terms of the results and what we're seeing for patients both those who are undergoing surgery and those who do not. 

Host: Really, such a great Center of Excellence. Dr. Newhams, as we wrap up, I'd like you to speak on a focus of patient reported outcomes, how you treat the patient, not just the cancer, the care closer to home and multiple locations that make it easier for patients to get radiation or chemo with clinics closer to the patient's home and how you work with those families and your multidisciplinary team and how it all comes together for these better outcomes. 

Kirsten Newhams, MD, MPH: I think, honestly, that is the key component of all of this. How do we bring the care to the patients and being able to travel to other places outside of Pittsburgh and bring care to those communities and the patients there is really important. And, and that's why we have our nurse navigators.

We have clinical health psychologists, people to help navigate that and figure out what support do you need to proceed with your therapy. And sometimes it's a combination of maybe the surgery will be in the city, but we can continue with chemotherapy, systemic therapy, radiation therapy in your community. So that way that we can limit travel because it's not just the patient, it's their family and their support network who we have to focus on too.

And so really it's a team approach and understanding how do we comprehensively support not just the patient but their team. 

Host: Beautifully said, and thank you so much, Dr. Newhams, for joining us today and really sharing your incredible expertise and your Center of Excellence at AHN. To learn more or to refer a patient, please call 844-MD REFER, or you can visit ahn.org. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network.

I'm Melanie Cole. Thanks so much for joining us today.