Transcription:
Northwestern Medicine: Treatment for Barrett’s Esophagus

Melanie Cole: Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Sri Komanduri. He's an Associate Chief of Gastroenterology and Hepatology and a Professor of Medicine in Gastroenterology, Hepatology, and Surgery at Northwestern Medicine, and he's here today to highlight Barrett's esophagus for us.

Dr. Komanduri, it's a pleasure to have you join us today. Before we get into this topic, can you tell us a little bit about yourself, your role at Northwestern Medicine and your research focus?

Srinadh Komanduri: Thank you. I appreciate the opportunity to bring my passion to this podcast. So, I have been in practice here at Northwestern for the last 15 plus years. As you mentioned, I currently serve as the Associate Chief for the Division. And my major role is not only programmatic and clinical growth like programs such as Barrett's esophagus and our cancer program, but also integrating the Northwestern Healthcare System in gastroenterology. And what that means, Northwestern is now a system of many hospitals encompassing many different providers and practice settings. And when we talk about programmatic growth clinically and academically on the research fronts, it gives us a very unique opportunity to not only look at an academic medical center, but look at the experience that patients have and, again, through research studies to look at outcomes that occur across a large healthcare system encompassing this type of population.

Melanie Cole: Well, thank you for that. So, let's dig into Barrett's esophagus a little bit. Tell us how it relates to GERD and esophageal cancer, and a little bit about the prevalence, because it does seem to be a little more common than people might realize.

Srinadh Komanduri: Yes. It's an interesting thing and perhaps scary on some fronts. As a gastroenterologist and all of my colleagues, we deal with all of these different entities in this continuum at different rates. And we like to call it a continuum of reflux to cancer because that's what we want our peers to understand. And when we're training, we want people to appreciate how this evolves and it is patients who have gastroesophageal reflux or, very simply stuff coming up and down from the stomach into the esophagus that causes injury that can develop into this pre-cancerous condition or Barrett's esophagus, ultimately the precursor for esophageal adenocarcinoma.

The interesting piece here is that we actually have a scenario where, if we can identify this pre-cancerous lesion, we can eradicate it or treat it with high rates of success upwards of 95%. So, we have a fantastic treatment. However, when you look at the prevalence or incidence of this cancer, it continues to rise significantly on an annual basis. And so, one might ask, "If we have such a great treatment, why does this cancer continue to rise?" And that is actually the crux of everything that's being innovated for in this disease and in this process, the denominator of patients. So, the patients that we know who have Barrett esophagus is very small. And the reason for that is most patients, while they have reflux that causes this, it tends to be not symptomatic. And so, the scary part there is the first time we see some of our patients, and my peers will attest to this is when they develop swallowing trouble and they actually have a cancer. And majority of patients who have gastroesophageal reflux don't have the typical heartburn or things we see on television, as what is truly understood as reflux. It's actually asymptomatic, and the problem there becomes how do we identify those patients.

And that's where, and we'll talk about this in this podcast, is really the excitement and the changes that have happened in this field that it's important for our peer physicians to understand because we're going to talk a little bit about screening and some of the novel innovations that will allow us to increase that denominator, and ultimately utilize the tools we have for treatment to make an impact on that rate of cancer incidence.

Melanie Cole: Well, that's so interesting, Dr. Komanduri. So when you say screening, when we think of colonoscopy for screening, that is just such an amazing advancement, right? And now, it's considered part of a well preventive program, but endoscopy is not always considered that. Do you think it should be? And are you considering implementing screening programs for esophageal cancers and Barrett's to catch them earlier?

Srinadh Komanduri: Yeah, great question. So, what's happened is that we've understood, the first step was understanding that so many of these patients can't be found with a typical process and the screening we have in place right now. And I do want to be thoughtful with the term screening. There's sort of population-based screening for asymptomatic individuals, that colonoscopy. But screening to date for esophageal cancer has really been about symptomatic patients with heartburn and come to a gastroenterologist with chronic reflux has been sort of the entry criteria. And as I've said, that's clearly been shown in many studies and in our work that that's not adequate because we're not finding the patients.

So this year, I was actually one of the leads for the American Gastroenterological Association's, Clinical Practice Update for Barrett's esophagus, which really helps providers in practice understand where the best practices are in certain disease states. We looked at the data and we had an expert panel assembled. And for the first time, we've made a best practice statement that introduces the concept of screening individuals who have other risk factors besides reflux. So, reflux is no longer a prerequisite. With that said, we want to be thoughtful because some of the other risk factors like age, Caucasian race and male gender are a huge population. So, we don't want to make screenings so voluminous and so difficult that it can't happen. But there are other criteria that have been shown to be major risk factors for this disease, including obesity, smoking and family history of esophageal cancer. And this is somewhat a low-hanging fruit for us to identify.

To the second part of the question, it doesn't necessarily have to be upper endoscopy. So, there are many new, innovative ways of doing this. We currently have piloted a novel strategy with transnasal endoscopy. So, this is an office-based sedation-less endoscopy that can be done. There are some new technologies around that which are disposable transnasal endoscopes, so they don't need reprocessing and the cost is drastically reduced. Secondly, there are many products that are available now and coming down the pipeline for what we call non-invasive screening of the esophagus. And these are little tethered capsules that patients can swallow and then you pull them out of the esophagus and they acquire cells. And this can be done in a lab. It can be done in a clinic. And that can be very inexpensive way to think about screening.

Again, to be fair, this is all in infancy. And in Northwestern, we've pioneered and started this high-risk screening clinic to look at some of these academically and try to provide our colleagues with the best recommendations and ways to consider screening. But I think that the exciting piece of this is for the first time we've opened the door for people to thoughtfully consider looking at patients who don't have typical reflux symptoms like heartburn and trying for once to increase that denominator and reduce the risk of esophageal cancer.

Melanie Cole: That's fantastic. And I love to hear about all of these exciting advancements coming down the line. It's really an exciting time in your field. So, tell us about the recent establishment of the comprehensive multidisciplinary program for Barretts and esophageal cancer at Northwestern Medicine, and why Northwestern is so uniquely set to handle such patients.

Srinadh Komanduri: Yeah. So as you can imagine, we've sort of described this or I've described this as a continuum, and I think when you look at reflux and Barrett's and cancer, your mind starts moving and, as my colleagues are probably thinking about this, it's so many touchpoints of various physicians that are involved. So, starting with the primary care level to the gastroenterologist, and then even subspecialized gastroenterologists who do the therapeutic procedures to our surgical colleagues. And then, you sort of overshadow that with dieticians with psychologists, all the other ancillary staff that are critical. You start developing this sort of wheel of providers that we've established. And we've put together representation at the highest level at Northwestern to sit down together and look at this continuum and how we best address screening in this population. And that's helped us really pioneer this clinic in a thoughtful way that's not just, "Hey, we can do this in the academic medical center," but "No. Hey, we can do this in any one of our system sites in any private practice that works out of an ASC or even a standard clinic." And this should be a program that's plug and play across our field in gastroenterology.

The unique thing about our clinic at Northwestern is we have the ability to provide that highest level of care and innovation across these different entities like reflux, which includes some of the world's leaders in physiology of reflux at Northwestern, and testing for objective data that tells patients how much reflux they have or don't have. My partners here have pioneered a lot of that sort of innovation around reflux. We also have some of the best thoracic and GI surgeons who do the most minimally invasive surgeries for some our patients who might actually require surgery because we have detected cancer early.

And then, myself and others do what's called endoscopic eradication therapy with things like radiofrequency ablation, cryotherapy, endoscopic resection to the sort of highest level, that the volume and the amount of patients and complexity I think we see at Northwestern amongst all these different providers and programs coming together as one is extremely unique and with the mindset of increasing screening and bringing more patients to these therapies, which can be so successful, I think makes us a very exciting and unique location for patients to come to.

Melanie Cole: I think so too. And it's such a comprehensive, multidisciplinary approach, as you said, with dieticians and so many different aspects of the healthcare field all working together. As we wrap up, Dr. Komanduri, what would you like the message to be for other providers? Tie the GERD to esophageal cancer continuum together for us. Tell us about Barrett's, where you see this all going. Just kind of wrap it up for us.

Srinadh Komanduri: Yeah, I think the biggest message is that we've entered an era for esophageal cancer that has so much innovation that's waiting to be used. We've entered an era where the understanding of the science has grown to a point where we think we can actually make a difference.

I think for my colleagues, having that mental understanding that as a gastroenterologist we don't treat the individual disease entities alone. And so, being a gastroenterologist involves seeing patients from GERD to esophageal cancer. I think more importantly is embracing some of these new innovations, looking at these new best practices and finally opening the dialogue for yourself, and talking to us at Northwestern and other centers who can provide some expertise and opportunities for patients, whether that's just clinically or in studies to look at screening in these patients is critical.

I think it's the first time in 20 years that we have the opportunity to be disruptive in this continued climb for esophageal adenocarcinoma and actually see our efforts in therapy have fruition to reducing one of the deadliest cancers we see. And it's all built around our colleagues and our programs like the one we have in Northwestern to be ready to be innovative and to be disruptive and ready to make an impact for our patients moving forward.

Melanie Cole: Well said, Dr. Komanduri. Thank you so much for joining us today. What a really interesting and informative podcast. You gave us a lot to think about as well when we talk about the future and screening. That was just so interesting. Thank you again. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/gastroenterology to get connected with one of our providers.

And that concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.