Penn Medicine's Gastrointestinal (GI) Cancer Program offers comprehensive care for the full spectrum of GI cancers. From diagnoses to complex cases to clinical trials and survivorship care, our team of experts works together to fight GI cancers.
Robert Roses, MD discusses Penn Medicine's Gastric Cancer and Surgery Program. He shares how our physicians are nationally and internationally recognized for their clinical expertise and research, and for their success in decreasing the incidence of local recurrence in most GI tumors and increasing the cure rate for tumors of the colon, rectum and pancreas.
Penn Medicine's Gastric Cancer and Surgery Program
Featuring:
Robert Roses, MD
Dr. Roses is an Associate Professor of Surgery at the Hospital of the University of Pennsylvania. He studied at Tufts University School of Medicine. He completed his residency at the Hospital of the University of Pennsylvania and his fellowship at the University of Texas - MD Anderson Cancer Center. Transcription:
Melanie Cole (Host): Welcome to this podcast series with the experts at Penn Medicine. I’m Melanie Cole and today, we’re discussing Penn Medicine’s gastric cancer and surgery program. Joining me is Dr. Robert Roses. He’s an Associate Professor of Surgery at the Hospital of the University of Pennsylvania. Dr. Roses, it’s such a pleasure to have you join us today. Please start by telling us a little bit about the prevalence of gastric cancers and what are you seeing in the trends?
Dr. Roses: In the United States this isn’t a very common disease I think a lot of hospital programs see a couple of cases per year and with that comes a lot of variation in approach. We see a lot of patients at Penn with this disease and we were able to come up with a more consistent approach that we could apply a couple of paradigms that we can follow for patients.
Host: Well then Dr. Roses for other providers, what types of services do you offer? Tell us a little bit about the physician services.
Dr. Roses: So, there are two big categories there are patients who are diagnosed with a so-called early stage stomach cancer. It’s a small localized tumor that doesn’t penetrate too deeply into the stomach wall and for those patients in general; the mainstay of treatment is surgical. There are a lot of patients however, who present with more advanced disease—either locally advanced disease, they’ve got a bulkier tumor or a more diffuse tumor, a tumor that penetrates more deeply into the gastric wall, has access to the lymphatics and might spread to more distant sites, and for those patients, the disease is often treated with a combination of surgery and often chemotherapy. And if a patient presents with those features; they’ll see me, they’ll see one of our medical oncologists. They may see a radiation oncologist, depending on the distribution of disease and we work collaboratively. We work together.
Host: Well what’s exciting in your field right now Dr. Roses? Tell us about some of the latest and most exciting advances in gastric cancers today.
Dr. Roses: So, I think the biggest thing that has had the largest immediate impact on treatment is an advance in the medical treatment of stomach cancers. So, in the past, there had been evidence for a couple of different approaches for so-called locally advanced gastric cancer. One approach would be surgery first and then chemotherapy and radiation afterwards. Another approach would be chemotherapy first and then surgery over the course of the last really two years, data emerged that supported a different regimen what they call FLA chemotherapy which seems to have a bigger impact on outcome and so, that data that evidence has provided momentum for more patients getting a chemotherapy first approach and then surgery. And we, like many other programs have been encouraged by our experience with that approach.
Host: What about things like advances in radiologic imaging?
Dr. Roses: So, maybe I can reframe the question slightly. What imaging do patients get? So, patients more often than not when patients are diagnosed with stomach cancer; they are diagnosed on the basis of an endoscopy. The GI doctor, the gastroenterologist does an endoscopy, he see a mass, does a biopsy, the biopsy shows a malignant tumor cancer of the stomach. And the frequently utilized modalities, imaging modalities are repeat endoscopy with endoscopic ultrasound which is most helpful for defining how big the tumor is and how deep it penetrates into the stomach wall.
Cross sectional imaging like the conventional CT scan which provides some information about the local tumor but might identify nearby or distant lymph nodes or other sites of disease. PET scan in some cases can provide additional information then often, particularly for patients with locally advanced disease, a bigger tumor or a tumor that seems to have spread to nearby lymph nodes, I’ll perform a diagnostic laparoscopy, a simple outpatient surgical procedure to rule out the presence of more distant spread of disease because stomach cancer has a proclivity to spread to the surfaces of the abdominal cavity.
If I understand your question, what you are getting at, is there anything we can do in the operating room to refine our surgical approach and we have explored that in collaboration with an intraoperative imaging program at Penn looking at the use of intraoperative infrared imaging; can it help better define what the margin of resection should be in the operating room or pick up on the presence of occult metastatic disease in the operating room. And we’ve explored that. It’s really in its infancy as a clinical tool.
Host: Who else is involved in the program? When a patient comes to you and they have seen you and other providers; who is following them? Who is helping them with diet, and all of the comorbid situations that might go along with gastric cancers?
Dr. Roses: Surgery, frequently medical oncology, sometimes our clinical nutrition group. We’ve also developed a patient support group and a nurse practitioner that I work closely with, Katelyn Perch, has really organized this great structure and patients who either are going to undergo gastrectomy or recovering from gastrectomy, come together and teach each other. And they are really the experts on recovery from gastrectomy.
Host: So, tell us about your care model. How is it improving the way patients receive their care and even outcomes? What makes it unique and what have you been seeing?
Dr. Roses: I think that we’ve evolved toward a much more coherent unified collaborative multidisciplinary process for patients. We have an approach in terms of every element of the process the critical studies that are going to dictate what the first best step is and as I mentioned, in general, it’s either going to be upfront surgery for early stage disease, frequently upfront chemotherapy for locally advanced disease; but there are some variations on that depending on how patients present. And getting people the right information early, eliminating unnecessary workup that isn’t helpful; I think has made a big impact and we’ve seen I think very good clinical outcomes, and I think patients have had a very good experience.
And then experience begets more experience. So, because patients have done well, we’re seeing more patients with this disease and we’ve taken a very consistent surgical approach and really tried to minimize some of the pitfalls that come with these big operations that are a challenge for patients. But we’re really tried to rachet down on some of the issues that people trip up on and try to ensure a really good outcome for the greatest proportion of patients. And I’ve been very gratified. It think we’ve been able to do that.
Host: Dr. Roses, as we wrap up, when do you feel for other providers that it’s very important for them to refer to the specialists at Penn Medicine?
Dr. Roses: I think what I would say is this is a challenging disease this disease requires a committed multidisciplinary team, good preoperative education, good postoperative education and follow up from a multidisciplinary group to ensure that people do well over a long period of time. You want a committed group of people who really care about the disease and who are going to weight the most contemporary evidence and choose the best first step and second step and third step.
And I think that’s what we’re trying to do and hopefully, we’ve been successful in doing it. My view is that we have. And so, we’re very committed to doing this and to providing really good care and that’s the message I’d want to convey to other physicians and to patients.
Host: Thank you so much Dr. Roses, for joining us today and sharing your expertise and telling us about the Penn Medicine’s Gastric Cancer and Surgery Program. That concludes this episode from the experts at Penn Medicine. To refer your patient to Dr. Roses, a specialist at Penn Medicine; please visit our website at www.pennmedicine.org/refer or call 877-937-PENN. Please remember to subscribe, rate and review this podcast and all the other Penn Medicine podcasts. I’m Melanie Cole.
Melanie Cole (Host): Welcome to this podcast series with the experts at Penn Medicine. I’m Melanie Cole and today, we’re discussing Penn Medicine’s gastric cancer and surgery program. Joining me is Dr. Robert Roses. He’s an Associate Professor of Surgery at the Hospital of the University of Pennsylvania. Dr. Roses, it’s such a pleasure to have you join us today. Please start by telling us a little bit about the prevalence of gastric cancers and what are you seeing in the trends?
Dr. Roses: In the United States this isn’t a very common disease I think a lot of hospital programs see a couple of cases per year and with that comes a lot of variation in approach. We see a lot of patients at Penn with this disease and we were able to come up with a more consistent approach that we could apply a couple of paradigms that we can follow for patients.
Host: Well then Dr. Roses for other providers, what types of services do you offer? Tell us a little bit about the physician services.
Dr. Roses: So, there are two big categories there are patients who are diagnosed with a so-called early stage stomach cancer. It’s a small localized tumor that doesn’t penetrate too deeply into the stomach wall and for those patients in general; the mainstay of treatment is surgical. There are a lot of patients however, who present with more advanced disease—either locally advanced disease, they’ve got a bulkier tumor or a more diffuse tumor, a tumor that penetrates more deeply into the gastric wall, has access to the lymphatics and might spread to more distant sites, and for those patients, the disease is often treated with a combination of surgery and often chemotherapy. And if a patient presents with those features; they’ll see me, they’ll see one of our medical oncologists. They may see a radiation oncologist, depending on the distribution of disease and we work collaboratively. We work together.
Host: Well what’s exciting in your field right now Dr. Roses? Tell us about some of the latest and most exciting advances in gastric cancers today.
Dr. Roses: So, I think the biggest thing that has had the largest immediate impact on treatment is an advance in the medical treatment of stomach cancers. So, in the past, there had been evidence for a couple of different approaches for so-called locally advanced gastric cancer. One approach would be surgery first and then chemotherapy and radiation afterwards. Another approach would be chemotherapy first and then surgery over the course of the last really two years, data emerged that supported a different regimen what they call FLA chemotherapy which seems to have a bigger impact on outcome and so, that data that evidence has provided momentum for more patients getting a chemotherapy first approach and then surgery. And we, like many other programs have been encouraged by our experience with that approach.
Host: What about things like advances in radiologic imaging?
Dr. Roses: So, maybe I can reframe the question slightly. What imaging do patients get? So, patients more often than not when patients are diagnosed with stomach cancer; they are diagnosed on the basis of an endoscopy. The GI doctor, the gastroenterologist does an endoscopy, he see a mass, does a biopsy, the biopsy shows a malignant tumor cancer of the stomach. And the frequently utilized modalities, imaging modalities are repeat endoscopy with endoscopic ultrasound which is most helpful for defining how big the tumor is and how deep it penetrates into the stomach wall.
Cross sectional imaging like the conventional CT scan which provides some information about the local tumor but might identify nearby or distant lymph nodes or other sites of disease. PET scan in some cases can provide additional information then often, particularly for patients with locally advanced disease, a bigger tumor or a tumor that seems to have spread to nearby lymph nodes, I’ll perform a diagnostic laparoscopy, a simple outpatient surgical procedure to rule out the presence of more distant spread of disease because stomach cancer has a proclivity to spread to the surfaces of the abdominal cavity.
If I understand your question, what you are getting at, is there anything we can do in the operating room to refine our surgical approach and we have explored that in collaboration with an intraoperative imaging program at Penn looking at the use of intraoperative infrared imaging; can it help better define what the margin of resection should be in the operating room or pick up on the presence of occult metastatic disease in the operating room. And we’ve explored that. It’s really in its infancy as a clinical tool.
Host: Who else is involved in the program? When a patient comes to you and they have seen you and other providers; who is following them? Who is helping them with diet, and all of the comorbid situations that might go along with gastric cancers?
Dr. Roses: Surgery, frequently medical oncology, sometimes our clinical nutrition group. We’ve also developed a patient support group and a nurse practitioner that I work closely with, Katelyn Perch, has really organized this great structure and patients who either are going to undergo gastrectomy or recovering from gastrectomy, come together and teach each other. And they are really the experts on recovery from gastrectomy.
Host: So, tell us about your care model. How is it improving the way patients receive their care and even outcomes? What makes it unique and what have you been seeing?
Dr. Roses: I think that we’ve evolved toward a much more coherent unified collaborative multidisciplinary process for patients. We have an approach in terms of every element of the process the critical studies that are going to dictate what the first best step is and as I mentioned, in general, it’s either going to be upfront surgery for early stage disease, frequently upfront chemotherapy for locally advanced disease; but there are some variations on that depending on how patients present. And getting people the right information early, eliminating unnecessary workup that isn’t helpful; I think has made a big impact and we’ve seen I think very good clinical outcomes, and I think patients have had a very good experience.
And then experience begets more experience. So, because patients have done well, we’re seeing more patients with this disease and we’ve taken a very consistent surgical approach and really tried to minimize some of the pitfalls that come with these big operations that are a challenge for patients. But we’re really tried to rachet down on some of the issues that people trip up on and try to ensure a really good outcome for the greatest proportion of patients. And I’ve been very gratified. It think we’ve been able to do that.
Host: Dr. Roses, as we wrap up, when do you feel for other providers that it’s very important for them to refer to the specialists at Penn Medicine?
Dr. Roses: I think what I would say is this is a challenging disease this disease requires a committed multidisciplinary team, good preoperative education, good postoperative education and follow up from a multidisciplinary group to ensure that people do well over a long period of time. You want a committed group of people who really care about the disease and who are going to weight the most contemporary evidence and choose the best first step and second step and third step.
And I think that’s what we’re trying to do and hopefully, we’ve been successful in doing it. My view is that we have. And so, we’re very committed to doing this and to providing really good care and that’s the message I’d want to convey to other physicians and to patients.
Host: Thank you so much Dr. Roses, for joining us today and sharing your expertise and telling us about the Penn Medicine’s Gastric Cancer and Surgery Program. That concludes this episode from the experts at Penn Medicine. To refer your patient to Dr. Roses, a specialist at Penn Medicine; please visit our website at www.pennmedicine.org/refer or call 877-937-PENN. Please remember to subscribe, rate and review this podcast and all the other Penn Medicine podcasts. I’m Melanie Cole.