Esophageal Cancer

 

Question.  Can you tell me something about esophageal cancer in brief?

Answer.  Esophagus is a food pipe which connects the mouth to the stomach. It is exposed to  similar cancer causing agents like oral cancer and stomach cancer. Esophageal cancers are of two types namely adenocarcinoma and squamous carcinoma.  These two mainly differ in location in the oesophagus. For example squamous cell carcinoma is more common in upper and middle thirds of the esophagus, while adenocarcinoma is more common in the lower part of oesophagus.  They are driven by different genetic changes and respond differently to the treatment. Treatment is also slightly different.

 

Question.  How can I suspect if I have esophageal cancer?

Answer.  Usually esophageal cancer is asymptomatic till late stages. Few symptoms which are common at the time of presentation are difficulty in swallowing which is more for solid food and weight loss. Symptoms depend on the location of the tumor also, for example if  tumor is in the upper part of oesophagus then difficulty in swallowing happens early while if it is in the lower part then it may be associated with vomiting.

It is difficult to suspect yourself if you have esophageal cancer, however you can detect it by endoscopy.

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Question. Can I prevent oesophageal cancer?

Answer. As I mentioned above, the risk factors for oral, gastric and esophageal cancers are common. Smoking and alcohol increase the risk of squamous cell carcinoma while chronic gastric Reflux may predispose you towards adenocarcinoma. It is important to visit a gastroenterologist for endoscopy if you have symptoms of gastric Reflux. There are few studies that NSAID like aspirin might help in preventing oesophageal cancer, but  is not routinely recommended as prevention. If detected at a very early stage by endoscopy, radiofrequency ablation can be done. In cases of Barrett oesophagus this can prevent the development of cancer.

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Question. Does my family history contribute to my risk of cancer of the oesophagus?

Answer.  Esophageal cancer is not considered to be part of familial genetic cancer syndromes. However if you have a strong family history of cancers it is possible that there is some hereditary germline mutation for tumor suppressor genes and you may be at risk of developing other cancers. It is best if you consult a genetic counselor.

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Question.  One of my relatives is suspected of esophageal cancer,  tell me something about the next set of action steps?

Answer.  Similar to any other cancer two things are most important in further treatment plan firstly Staging and secondly typing of the cancer.

For Staging we need to do endoscopic ultrasound which will tell about the depth of the tumor,  CT scan or pet CT scan of full body. Sometimes laparoscopic confirmation of seeding of abdomen is done before any definite treatment.

For typing of cancer biopsies are taken during endoscopy.

Sometimes the disease is metastatic at the time of presentation, in that situation biopsy need not be done from endoscopy, but can be done from any of the metastatic sites in the body.

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Question.  What is the implication of Staging?

Answer.  Stage 1, 2, 3  cancers should receive curative intent treatment. This treatment may include endoscopic radioablation or a combination of surgery with chemotherapy or radiation.

In stage 4 our intention of treatment changes from curative to control of the disease and usually chemotherapy alone or in combination with certain other agents can be offered  Example Ramucirumab can be combined with docetaxel chemotherapy.

 

Question.  My relative is unable to eat because of esophageal cancer, how can I help?

Answer.  Since esophageal cancer is present in food pipe it is natural that these patients will have trouble swallowing. However in case where patient is finding it difficult to eat and losing weight, patient can go for permanent or temporary stenting of oesophagus.  This makes the calibre of oesophagus near normal again and patient starts eating comfortably again.

If for some reason stenting is not an option then a flexible plastic tube known as feeding tube can be inserted from nose or mouth till stomach or intestine. From this tube liquid material can be given.

A dietitian should always be consulted to increase the calories and nutrition while maintaining  quantity of food.

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Question.  Tell me about surgery in esophageal cancer?  Does it have a major effect on lifestyle?

Answer.   This question is a detailed discussion between surgeon and patient because the type of surgery depends on multiple factors like fitness of the patient, the location of the tumor, and the size of the tumor.

Form of modification definitely will be required after the surgery.

 

Question.  I heard about immunotherapy and targeted therapy in oesophageal cancer,  can you throw some light on this?

Answer.  Targeted therapies like trustuzumab can be used if it is a stage 4 disease with HER-2 mutation. In its absence there is no additional benefit of giving  trastuzumab.

There are other agents which do not depend on HER-2 mutation and can be offered for example ramucirumab. This also depends on which chemotherapy has been received in the past.

Role of immunotherapy in esophageal cancer is not confirmed and so is not routinely offered.

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Stomach Cancer

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Question.  Does stomach cancer happen only in adults?

Answer.  In most cases it happens in adults, however a minority of patients can develop at a younger age aur even in childhood. These cases are usually associated with certain  high-risk genetic mutations carried in their family. There are certain surgeries which can be done in case such high risk genetic mutations are present.

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Question. What are the risk factors for gastric cancer and can I prevent them?

Answer.  There are environmental, medical and genetic conditions which can cause cancer in the future.

Medical conditions include H pylori infection, Pernicious Anemia, stomach polyps and atrophic gastritis.

Genetic conditions examples are familial syndromes like Li fraumeni syndrome, familial adenomatous polyposis and Lynch syndrome.

Dietary factors which are most important are diet low in fruits and vegetables, high salt diet and smoked food. Smoking also contributes to gastric cancer.

There are  few occupations which predispose to gastric cancer. for example rubber and auto industry employees have higher risk of stomach cancer.

 

Question. Is there a routine screening test available for stomach cancer for early detection?

Answer.  There is no standard screening test for gastric cancer. However some tests can be done  for early detection, example upper endoscopy for serum pepsinogen levels. however doing this test is not found to decrease the risk of dying from stomach cancer.

We offer this screening test to patients of pernicious anemia or genetic syndromes as mentioned above  namely f a p and hnpcc or Lynch syndrome.

 

Question. I have learnt from other topics on your website that treatment of cancer depends on Staging and typing of cancer.  How do we stage or type stomach cancer?

Answer.  The set of investigations are quite common between esophageal and stomach cancer so you will be required to undergo endoscopy with biopsy,  CT scan or pet CT scan of the body and maybe a laparoscopy

Stage 1 and 2  means that disease is limited to stomach or has just started spreading out of it,  stage 3 means it is locally advanced with nearby areas and lymph nodes being involved.  While stage 4 means this has already spread to distant organs and we can now only control this disease.

 

Question.  Tell me something about treatment of stomach cancer?

Answer.  Treatment depends on the stage.  For stage 1 upto 3 we offer surgery followed by chemotherapy. If in surgery complete removal was not possible then we also give radiation. In today's time people also offer intraperitoneal chemotherapy in certain cases where Mitra P is given in the abdomen at the time of surgery. Sometimes the chemotherapy is warmed and then it is known as HIPEC for hyperthermic intraperitoneal chemotherapy.

Stage 4  we usually do not do surgery.  Treatment is primarily based on chemotherapy with combination of targeted therapy. Immunotherapy is also being explored in stomach cancer and can be offered if certain test known as pdL1 is high.

 

Question.  If stomach cancer recurs then does it mean there is no other treatment?

Answer.  I will assume that you mean to say that it is a stage 4 disease in which after certain surgery or chemotherapy disease has come back, not only in the abdomen but maybe in other parts of the body as well.

This does not mean that there is no more treatment, however we cannot expect a cure in this situation. With appropriate treatment we can expect control of disease over the next few months.

 

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Pancreatic Cancer

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Question.  I heard that Steve Jobs also suffered from pancreatic cancer,  he is from educated and advanced society, how come he was not cured of it?

Answer.  Pancreatic cancer is of two types: from exocrine cells or neuroendocrine cells.  Exocrine cell tumors are more common and are usually diagnosed at an advanced stage.  Once a cancer is diagnosed at an advanced stage, it usually is not curable with present  scientific treatment. We can control or delay its progression.

 

Question. Tell me something about treatment of pancreatic cancer?

Answer.   As with any other cancer, treatment depends on the stage of the cancer.

Staging is done by CT scan of Thorax, abdomen and pelvis. In pancreatic cancer surgery plays a dominant role. Depending on the local extent of the cancer one can remove pancreas alone or in combination with nearby structures like gallbladder, stomach, small intestine, bile ducts with lymph nodes.

If a complete surgery cannot be performed based on the CT Scan then a bypass surgery is done or palliative intent stents are placed.

Certain patients are borderline resectable. In such patients operating at the time of presentation is not possible because of local extension but if somehow we reduce the size of the tumor then maybe surgery is possible. Hence in such patients we give chemotherapy first followed by rechecking by CT scan and if there's tumor reduction as per our expectation then surgery can be done.

Pancreatic cancer is known to have inadequate outcome despite aggressive treatment. Hence almost every case we have to give chemotherapy after surgery. There are many protocols which are followed all over the globe, however folfirinox  is considered to be the standard of care for fit patients.

Role of radiation is in patients with high risk factors and after incomplete surgery.

 

Question.  Is there a special pancreatic cancer diet?

Answer.  Yes. Since pancreatic enzymes are important in digestion of food, after pancreatic removal one must receive enzyme supplementation for digestion.  This is an often neglected aspect of pancreatic Cancer care.

I also advise taking pancreatic enzymes even if surgical removal is not done but a reduction in pancreatic function is expected because of cancer.

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Question.  Is there anything novel in the pancreatic cancer treatment?

Answer.  The latest  development in the field of pancreatic Cancer is a drug group known as PARP inhibitors such as olaparib. This is shown to have a good response especially if the pancreatic cancer is positive for certain mutations like BRCA2 and homologous repair deficient.