Transcription:
Treatment Options for Esophageal Cancer

Melanie Cole (Host):  If you found that you’ve had difficulty swallowing or weight loss without trying, you might want to see your doctor because you do need to be checked for esophageal cancer. My guest today is Dr. Benjamin Kozower. He’s a board-certified surgeon whose specialties include esophageal cancer and lung cancer at UVA. Welcome to the show, Dr. Kozower. Tell us a little bit about esophageal cancer and who is at risk for this?

Dr. Benjamin Kozower (Guest):  Sure. Well, there are really two main types of esophageal cancer. First type is called squamous cell and the two main risk factors for that are really smoking and then use of alcohol. In the US, that’s actually not as common now, although it previously was the most common form. Now, the most common form occurs at the bottom of the esophagus close to where the esophagus meets the stomach. That is dramatically increasing in the US. In fact, that’s one of the only two cancers that’s actually increasing in frequency. The cause for that is heartburn. The reflux that we have of contents coming from the stomach and actually moving up into the esophagus is really not good for the lining of the esophagus and that’s what predisposes patients to then have changes in their esophagus that ultimately can go on to cancer.  

Melanie:  Because we’re experiencing more heartburn, do you advise that people kind of keep an eye on that or get checked for Barrett’s esophagus, things that might increase their risk? 

Dr. Kozower:  Absolutely. That’s really the key to this whole thing. Unfortunately, as our population continues to kind of grow in weight, that puts us at increased risk for heartburn and for reflux, and then you mentioned that term, Barrett’s esophagus. So patients who have reflux who know they have heartburn, it’s not just enough to take something over-the-counter, and now some of the stronger medications can actually be purchased over the counter. They’re really good at helping with symptoms, but what patients don’t understand is that they decrease the amount of acid in the stomach. That helps patients feel better, but they don’t stop the contents from the stomach from going up into the esophagus. Even though you’re feeling better, you could still potentially have a lot going on that you’re not aware of. So, for patients who really need to be on this medications long term, it’s really important to get checked by their physicians, to have an endoscopy performed which is where a scope can get put in through the mouth and you can actually look at the esophagus. If you find something that shouldn’t be there, then you could actually take a sample of that. Then you can find out exactly what’s going on. 

Melanie:  Dr. Kozower, does endoscopy, like colonoscopy, if you find something or polyps in there or something and you remove them, does that then reduce your risk as it would in a colonoscopy? 

Dr. Kozower:  Yeah, it’s very different. You don’t really get polyps in your esophagus like you do in colorectal cancer, so they’re not really analogous. But what you can do is you can identify patients who have Barrett’s esophagus or who potentially have a very early stage esophageal cancer that could be cured. 

Melanie:  What are some treatment options if you do find that they have early stage esophageal cancer? 

Dr. Kozower:  Yeah, the most exciting treatment option is now to treat it endoscopically. In this kind of injury that takes place to the esophagus, you first develop Barrett’s esophagus and then you go on to something called dysplasia, and you can get as complicated as you want, but just keeping things fairly simple, then dysplasia goes on to cancer. The most exciting treatments now are treatments that are endoscopic. The first thing for patients who have bad dysplasia, which is a strong risk factor for cancer, is you can actually ablate that endoscopically using radio frequency ablation. That dramatically reduces the risk for cancer. The other exciting thing is, for patients with a very early cancer or very small nodule you actually can take it out endoscopically. That combination of treatments is quite effective. Unfortunately, most patients are not identified that early. For the majority of patients, the primary treatment is surgery; you have to remove the esophagus. It is a big operation so patients have to be fairly healthy, but we can do that in all different ages. Then the other treatments are chemotherapy and radiation therapy. One of the things we’ve learned over the last 10 years is for the majority of patients who present with symptoms – when you started this segment, you said for patients having trouble swallowing or patients who have lost weight. Unfortunately, when you get those symptoms, it’s typically not an early stage cancer, meaning, that the cancer has kind of gone through the wall of the esophagus and also involves some lymph nodes close by. The best treatment for those patients is combine therapy using essentially all three of those treatments. Radiation and chemotherapy first, followed by surgery. It’s a lot of treatment for patients, but fortunately, we’re having more and more success with it. 

Melanie:  If somebody does have to have a portion of their esophagus removed, tell us how that affects their daily life because this is a scary type of cancer and so people don’t know what to expect if they had to go through this type of treatments. 

Dr. Kozower:  It’s a great question. When patients heal, they ultimately can eat anything they want. What they can’t do is they can’t eat the same quantity of food. Typically, we have patients eating six smaller meals a day instead of having three large meals. Unfortunately, with Christmas coming up, you’re probably never going to have a huge plate of food like you used to, but ultimately when everything heals, you can eat all types of foods. The other problem is that everybody gets some reflux. We talked about reflux being the cause for esophageal cancer, but we actually when you take the esophagus out, you make a tube out of the stomach and you bring that tube up and you’d reconnect it with the esophagus. You really have to have patients sleeping with their head of the bed elevated. You don’t want to eat right before bed. Those lifestyle changes along with smaller and more frequent meals are things that we have patients do for the rest of their lives. 

Melanie:  Tell us about some of the really exciting advances in esophageal cancer today and things you’re doing at UVA. 

Dr. Kozower:  I think the most exciting treatment is really the endoscopic resection. That’s when you can identify these patients at an earlier stage. That’s why it’s so important for patients with symptoms of heartburn who need to be on medicines, whether it’s the proton pump inhibitors that most people take and there’s many different names for them now, it’s really important to get that endoscopy early and make sure that there’s nothing bad going on. The most exciting treatment is instead of the big surgery that I was talking about is to treat it from the inside. From a surgical standpoint, we now do at UVA about a third of our surgeries in a minimally invasive fashion, and so we’re able to accomplish the same results but with a lot less pain and decreased time in the hospital. The third major change is this use of kind of multimodality therapy or the combination of the therapies. It’s a lot easier for patients to get the chemotherapy before surgery than it is after. That’s really important. God forbid any cancer cells are out of the esophagus in the blood stream. The purpose of the chemotherapy is to be able to attack those early. 

Melanie:  In just the last minute, Dr. Kozower, tell the listeners why patients should come to UVA cancer center for their care. 

Dr. Kozower:  At the University of Virginia, we really do have the latest in multidisciplinary care, so we have a dedicated team of gastroenterologists and they’re the ones who handle the endoscopic side, doing things with the scopes. Then we have three dedicated thoracic surgeons who do all, what we call, general thoracic surgery. So we don’t do heart surgery, we don’t do general surgery, we just do thoracic surgery, and our outcomes even compared with national benchmarks are quite good. Then we have a dedicated team of both medical and radiation oncologists who are used to taking care of patients who unfortunately have esophageal cancer. I think that’s part of the main advantage that we can offer is that we have a team including our nurse coordinators, who can really help guide patients through this whole process. When I meet people the first time, I tell them that it’s a long journey. It’s not a sprint. You really have to kind of understand that you’re buying into this, and in the end, you’re going to have a pretty good quality of life, but it does take some work to get there. 

Melanie:  Thank you so much. For more information on the UVA Cancer Center, you can go to uvahealth.com. That’s uvahealth.com. You’re listening to UVA Health Systems Radio. I’m Melanie Cole. Have a great day.