Transcription:
Advancing Outcomes of Esophageal Cancer through Early Detection, Clinical Trials, Minimally Invasive Surgery and More

Melanie Cole (Host):  Welcome. Joining me today, is Dr. David Odell. He’s an Associate Professor of Thoracic Surgery at the Northwestern Medicine Robert H. Lurie Comprehensive Cancer Center. He specializes in minimally invasive treatment of esophageal cancer and he’s joining me today, to share more about Northwestern Medicine’s approach to treating esophageal cancer. Dr. Odell, it’s a pleasure to have you with us today. Tell us a little bit more about esophageal cancer and what some of the specific risk factors are.

David Odell, MD (Guest):  So, esophageal cancer is actually the fastest growing malignancy in the United States and really across the world. It’s a disease that is driven by several things. In North America, most frequently it’s associated with long term exposure to acid reflux. And there’s some exposure or some association with exposure to cigarette smoke as well.

The disease is characterized oftentimes by no symptoms at it very early stage. And in later stages, oftentimes, the first thing that we see is when folks develop some difficulty in swallowing.

Host:  Dr. Odell, and this is just in your opinion; when we talk about diagnoses and as you said, sometimes the symptoms have progressed to the point where there is swallowing issues; where do you stand as to implementing screening programs for esophageal cancer similar to the colonoscopy?

Dr. Odell:  So, we don’t currently have any recommendations that support screening routinely for these patients as you would with a colonoscopy or as you would with mammograms for diseases like breast cancer. And it’s really unfortunate that we don’t have a better mechanism for identifying patients early because we have such better treatments at earlier phases of disease. That said, we do have a good opportunity to capture the disease early in patients that have symptomatic reflux disease. I think for that group of folks, which are really the group at highest risk for the development of esophageal cancer; it’s really important to have an upfront conversation with your doctor about getting an endoscopy in that setting to make sure that number one: there’s not a potential treatable cause for the reflux disease like a hiatal hernia and number two: to make sure that it’s not an early sign of progression to cancer.

Host:  So, as we’re talking about treatments, surgery being the most common form of treatment for patients with esophageal cancer; but there are several new advances in surgical treatment including minimally invasive options. Share some of the latest options that you are doing at Northwestern.

Dr. Odell:  That’s absolutely right. So, in the earliest phases of the disease, where the disease develops in just the lining of the esophagus; there are some minimally invasive options that allow us to avoid traditional surgery altogether, endoscopically. So, using a scope that goes down through the mouth and into the esophagus; we can actually dissect away the cancer if it’s at a very superficial stage in just the lining of the esophagus and maintain the rest of the organ while removing the cancer. That’s kind of the best case scenario and that’s an advance really in the last ten years that some of our colleagues here in our Gastroenterology Department have pioneered.

When it comes to patients that have more traditional cancer, meaning cancer that’s gone beyond just the lining and started to invade into the wall of the esophagus; this is something that traditionally required a massive operation with large incisions in the abdomen and in the chest. We have been able to transition to doing this operation now as you said, minimally invasively through small incisions about the size of a fingernail using video cameras and high tech chopstick like instruments where we can operate on the inside without having the same amount of incisional trauma to the patient on the outside.

Host:  Wow, it really is amazing and due to the sensitivity and intricate nature of this type of cancer; are there some technical considerations you’d like other providers to know about because the after effects of this type of cancer can really affect a patient’s whole life whether it’s swallowing, speaking, eating, self-esteem, appearance; all of those things can come into play. What would you like other providers to know about the effects that minimally invasive has for these patients and the effect on their lives?

Dr. Odell:  You’re absolutely right Melanie. This is an operation that is life changing for patients. And it can be life changing in very good ways because it can cure them of a disease that is otherwise quite lethal. But it has significant changes for patients in terms of function and can impact their quality of life. If the operation goes well, actually the quality of life remains quite preserved for patients. And I think this is one of the things that has been a source of some misinformation through the years that this is an operation that’s almost worse than the disease itself.

Many of my patients by the time they are two to three months out from surgery, actually feel as good as they did before they were diagnosed with their cancers. It’s really quite amazing where we’ve come with things. I think there are two areas where it becomes particularly important. One is right around the time of recovery from surgery. It’s probably the biggest risk factor that patients have after this operation is the development of respiratory complications. Because you can imagine, with an operation that takes place both in your abdominal cavity and in the chest cavity; it can become very difficult to get up and move around, to cough, to breathe normally and the largest risk that we had after this operation traditionally, was the development of pneumonia.

By transitioning to minimally invasive surgical techniques, it makes it much easier for patients to get back up on their feet and breathe normally. And we’ve been able largely to eliminate that risk factor for pneumonia in our patients. I think that from a long-term perspective as well, it’s important to understand that we’re able to now return patients to a very good quality of life both psychologically and functionally by reducing the burden of recovery that they have.

Host:  Well that’s so important and another important aspect Dr. Odell, the Lurie Cancer Center and Northwestern Medicine’s Thoracic Surgery team is focused on engaging multidisciplinary teams to best treat a patient and this to me, seem especially important for esophageal cancer patients who may have special considerations when it comes to diet, and as you mentioned, exercise, moving around. Speak more for us about that team-based approach and why is that multidisciplinary approach so important for these patients?

Dr. Odell:  Multidisciplinary care is essential in the treatment of patients with esophageal cancer. You alluded to some of the things that are important in recovery, but it even starts before that. Our best outcomes are when we combine different mechanisms of treatments. So, for the majority of our patients, not only do they need care surgically, but a combination of chemotherapy and radiation is often also a part of their treatment plan, usually before they have an operation. So, having a team that is well-integrated and coordinates together this course of treatment is really what is essential to provide patients with an opportunity to have a good outcome.

We have a very close knit and integrated multidisciplinary oncology care team here. We meet weekly. Our surgeons, our medical oncologists, our radiation oncologists, our gastroenterologists; essentially all of the physicians who are involved in the care of patients with esophageal cancer to carefully and thoughtfully review each patient’s case and determine together what the best course of treatment is going to be and make sure that as they progress through that, regardless of which physician is primarily directing care at any given moment; the entire team remains involved. And those handoffs are seamless.

As patients then progress through their treatment; many different issues can arise. Swallowing difficulty is the thing that we see most commonly, and we have a really, really phenomenal team of dieticians and experts who can help with the modification and modulation of diet for our patients so that they can continue to get the nutritional support that they need both before, during and after their surgical recovery.

And then in addition, there is quite a physical toll that’s taken on patients as they progress through treatment for esophageal cancer and we’re very fortunate to have an expert team of physical and occupational therapists who can help to both help with patients who are recuperating after surgery but more importantly, to put folks in the best possible condition that they can be coming into their treatment.

Host:  Wow good points, all. Such a comprehensive approach. Looking to the next ten years, Dr. Odell, tell us about some of the latest research advances in esophageal cancer. What would you like oncologists to know that could be practice changing. Give us a little blueprint for further research.

Dr. Odell:  Yeah, esophageal cancer is one of these areas where we really are having an explosion of new thoughts and ideas that I think are going to transform the way that we approach treatment of this disease as we move forward. We really only in the last ten years or so have begun to develop a protocolized and as you say kind of treatment blueprint for how we approach it and we’re continuing to refine that. We have a number of active clinical trials looking at medications that harness the effectiveness and impact of our body’s own immune system in the treatment of this disease. These are things that have shown to be very, very useful in other diseases like lung cancer and melanoma.

We are continuing also to innovate from a technical perspective the things that we do endoscopically and in the operating room to further push the window of what we can do in the sense of offering minimally invasive surgical options to patients. We’re starting to do many of these operations using assistance of robotic technology which allows for even finer and more precise dissection and we think better outcomes for patients as well.

Host:  What a great topic and so interesting as you said, what an exciting time to be in this field because there’s so much going on. As we wrap up and we know that early detection is going to play that critical role in improving survival rates and outcomes that you are seeing; what would you like other providers to know about screening, treatment, referrals, when you feel it’s important that they refer to the specialists at Northwestern Medicine?

Dr. Odell:  First and foremost, as you alluded to, detecting this disease early really offers patients the best chance of a good long-term outcome. So, I think it’s important for all providers who are treating patients who present with things that are very common as complaints like heartburn that they really think critically about whether or not this is a patient who might benefit from getting an endoscopic evaluation. I think almost all patients who have heartburn that doesn’t respond to the very first line medical therapies probably deserve an endoscopy to make sure that it’s not a more complex situation.

Many of the cancers that we see that are caught early are detected because physicians have just this approach to treatment. I think as we look at then kind of the next phases, those patients who are already diagnosed with cancer, as we’ve discussed, this is a disease that is very challenging to care for, requires a really expert multidisciplinary team and is something that is still rare enough that I think it’s relatively difficult to find groups who work together in this kind of coordinated way. And I think that regardless of the patient; referral to a center that approaches care in this multidisciplinary fashion is what really will lead to that patient having the best opportunity for a good outcome.

Host:  Well it certainly will and thank you so much Dr. Odell for sharing your expertise and describing this so very well and what’s going on in the field. Thank you again. And that’s concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient, or for more information on the latest advances in medicine; please visit our website at www.nm.org to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. For more health tips and updates on the latest medical advancements and breakthroughs please follow us on your social channels. I’m Melanie Cole.