Esophageal Cancer Awareness Month

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anish Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:14latest information on cancer care
00:14 --> 00:15by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week, it's a conversation about
00:21 --> 00:24esophageal cancer with Doctor Harry Aslanian.
00:24 --> 00:26Dr. Aslanian is a professor of medicine
00:26 --> 00:28and director of endoscopic ultrasound
00:28 --> 00:31at the Yale School of Medicine,
00:31 --> 00:33where Doctor Chagpar is a professor
00:33 --> 00:34of surgical oncology.
00:35 --> 00:37Doctor Aslanian, maybe we can start
00:37 --> 00:39off by you telling us a little bit more
00:39 --> 00:41about yourself and what it is you do.
00:41 --> 00:43I'm a gastroenterologist
00:43 --> 00:45and I work as part of the
00:45 --> 00:47Yale Advanced Endoscopy team.
00:47 --> 00:51So endoscopy is sort of its own
00:51 --> 00:53subspecialty in gastroenterology where we
00:53 --> 00:57perform a variety of specialized scope
00:57 --> 00:59procedures very commonly to diagnose
00:59 --> 01:02and stage and more frequently
01:02 --> 01:05also treat early cancers of the
01:05 --> 01:06esophagus, stomach,
01:06 --> 01:10small bowel, colon and we
01:10 --> 01:13can also diagnose and treat some
01:13 --> 01:15pancreas and biliary diseases.
01:16 --> 01:18That sounds awesome.
01:18 --> 01:20The question that I
01:20 --> 01:23have for you is,
01:23 --> 01:26we talk a lot about cancer on this show.
01:26 --> 01:28Clearly it is Yale Cancer Answers, but
01:28 --> 01:31we don't often talk about
01:31 --> 01:32esophageal cancer.
01:32 --> 01:35So can you paint
01:35 --> 01:37the landscape for us on that?
01:37 --> 01:40What exactly is this cancer?
01:40 --> 01:41How common is it?
01:41 --> 01:43Who gets it, that kind of stuff?
01:44 --> 01:47Yeah, there's a lot of interesting features.
01:48 --> 01:50We often take the esophagus
01:50 --> 01:52for granted and think of
01:52 --> 01:54just a tube that we
01:54 --> 01:56are able to swallow something.
01:56 --> 01:58And swallowing is quite a complex
01:58 --> 02:01mechanism to get something to transfer
02:01 --> 02:03from our mouths into the esophagus.
02:03 --> 02:05But once it reaches the esophagus,
02:05 --> 02:09the esophagus also has a
02:09 --> 02:12musculature like an electrical
02:12 --> 02:15motor that has a stripping wave
02:15 --> 02:18that carries the food down from the
02:18 --> 02:21upper esophagus towards the stomach
02:21 --> 02:24and then there's a valve called the
02:24 --> 02:27lower esophageal sphincter that
02:27 --> 02:30coordinates with that electrical motor.
02:30 --> 02:32So we want to open that Valve to
02:32 --> 02:35let the food out of the esophagus
02:35 --> 02:37at the right time because then the
02:37 --> 02:39stomach does its important job.
02:39 --> 02:41It's a very acidic environment and it's
02:41 --> 02:44grinding up and digesting the food,
02:44 --> 02:45so we don't want
02:45 --> 02:48all of that acid and bile that's in the
02:48 --> 02:51stomach to be coming up into the esophagus.
02:51 --> 02:55So that lower valve will be shut most
02:55 --> 02:59of the time and because bile, which
02:59 --> 03:02happens to be alkaline and then stomach
03:02 --> 03:04acid can be very irritating to the
03:04 --> 03:06esophagus and cause a lot of inflammation.
03:06 --> 03:10So the symptoms of heartburn are
03:10 --> 03:13extremely common and we all experience
03:13 --> 03:16that usually at some point or other and
03:16 --> 03:19that's also why the medications to
03:19 --> 03:22block stomach acid called proton pump
03:22 --> 03:25inhibitors and the older ones H2 blockers,
03:25 --> 03:28which would be like a brand names
03:28 --> 03:31like Pepcid or Prilosec are extremely
03:31 --> 03:32common and are
03:32 --> 03:35multibillion dollar medications across the
03:35 --> 03:37world because these symptoms are so common.
03:37 --> 03:39And just a little more
03:39 --> 03:40background about the esophagus.
03:40 --> 03:43So the esophagus itself is
03:43 --> 03:46normally lined by squamous mucosa.
03:46 --> 03:47So those are the kind of
03:47 --> 03:49cells that line our skin.
03:49 --> 03:52And one type of cancer that
03:52 --> 03:54arises from the squamous line
03:54 --> 03:57is called squamous cell cancer.
03:57 --> 04:00And that can occur anywhere throughout the
04:00 --> 04:03esophagus and it can be multiple locations.
04:03 --> 04:05And that's the cancer that's much
04:05 --> 04:07more common around the world.
04:07 --> 04:10So esophageal cancer overall is the 8th
04:10 --> 04:12most common cancer worldwide and the
04:12 --> 04:156th most common cause of cancer death.
04:15 --> 04:19But in countries across Africa and Asia,
04:19 --> 04:20there's some
04:20 --> 04:23areas where there's a lot
04:23 --> 04:25of squamous cell cancer and
04:25 --> 04:27factors that are thought to contribute
04:27 --> 04:28to that include smoking,
04:28 --> 04:33alcohol, and poor nutrition.
04:33 --> 04:35But in the United States,
04:35 --> 04:37in Western countries,
04:37 --> 04:41a different type of cell is becoming the most
04:41 --> 04:44common cancer that we call adenocarcinoma.
04:44 --> 04:46So the cells lining the
04:46 --> 04:48stomach are different types.
04:48 --> 04:50And there's this process that's thought
04:50 --> 04:53to be related to chronic acid reflux
04:53 --> 04:56where the more resistant
04:56 --> 04:58stomach lining called columnar cells
04:58 --> 05:01grow upwards into the bottom of
05:01 --> 05:04the esophagus to kind of make that
05:04 --> 05:07more resistant to stomach acid.
05:07 --> 05:09And some people think that might
05:09 --> 05:10have been an evolutionary
05:10 --> 05:12process as an adaptation to
05:12 --> 05:14reduce the symptoms of heartburn.
05:14 --> 05:16So it seems like a fine thing,
05:16 --> 05:18but unfortunately there's a
05:18 --> 05:22small risk that that lining,
05:22 --> 05:24which is metaplasia when one cell
05:24 --> 05:26moves from one spot to another,
05:26 --> 05:27sometimes we call it Barretts
05:27 --> 05:29Esophagus has a greater risk
05:29 --> 05:32of getting precancerous changes,
05:32 --> 05:35and that can lead to
05:35 --> 05:36adenocarcinoma of the esophagus,
05:36 --> 05:39which is the most common type
05:39 --> 05:40we see in the United States.
05:43 --> 05:45And so in the US,
05:45 --> 05:47how many people every year get
05:47 --> 05:50esophageal cancer and how would they
05:50 --> 05:52know what the first symptoms are?
05:52 --> 05:54I mean, is that heartburn?
05:54 --> 05:55But as you mentioned,
05:55 --> 05:57heartburn is really kind of common.
05:57 --> 05:58Yes, absolutely.
05:58 --> 06:02So that is part of the challenge.
06:02 --> 06:04I think esophageal cancer accounts
06:04 --> 06:07for about 1% of all cancers in the
06:07 --> 06:09United States which amounts
06:10 --> 06:13to about 16,000 people a year.
06:13 --> 06:16And like many situations
06:16 --> 06:18with cancer screening,
06:18 --> 06:20the symptoms either develop too late
06:20 --> 06:23and if we go by symptoms then the
06:23 --> 06:26cancer is already in advanced stage.
06:26 --> 06:28But the early symptoms may be
06:28 --> 06:30so common that very few people
06:30 --> 06:32actually have those symptoms.
06:32 --> 06:36So the late symptoms of esophageal cancer
06:36 --> 06:40would be difficulty swallowing so
06:40 --> 06:42if a cancer grows
06:42 --> 06:44in the tube of the esophagus,
06:44 --> 06:46it starts to take up space and
06:46 --> 06:48it'll block the transit of food.
06:48 --> 06:51So certainly if someone had
06:51 --> 06:53new onset difficulty swallowing,
06:53 --> 06:57that's very important to see your doctor
06:57 --> 07:02and investigate that and then
07:02 --> 07:05we know that acid reflux is a risk factor
07:05 --> 07:08for developing Barretts esophagus and
07:08 --> 07:11for chronic inflammation of the esophagus.
07:11 --> 07:13And like anywhere in the body,
07:13 --> 07:14if you have chronic inflammation
07:14 --> 07:16that puts stress on the cells
07:16 --> 07:19and may lead to the cells having
07:19 --> 07:20trouble repairing themselves and
07:20 --> 07:23in some type of abnormality like a
07:23 --> 07:24precancerous condition developing.
07:24 --> 07:27So that is the challenge then if
07:27 --> 07:30we have a very common symptom like
07:30 --> 07:32heartburn or sometimes we call it
07:32 --> 07:34gastroesophageal reflux disease.
07:34 --> 07:38How do we then identify amongst all
07:38 --> 07:41of that large group which people
07:41 --> 07:43would benefit from screening?
07:43 --> 07:45And that's been looked at,
07:45 --> 07:48and like many areas
07:50 --> 07:52it's not still not entirely clear
07:52 --> 07:54because only a small proportion of
07:54 --> 07:57people that have acid reflux will
07:57 --> 07:59have Barretts esophagus or will be
07:59 --> 08:01predisposed to esophageal cancer.
08:01 --> 08:03But typically the most effective
08:03 --> 08:06way we do that is by endoscopy.
08:06 --> 08:09So that's a scope procedure with a light
08:09 --> 08:11and a camera at the end of the scope,
08:11 --> 08:14and we can carefully examine the lining,
08:14 --> 08:16the mucosal lining of the
08:16 --> 08:18esophagus and the junction,
08:18 --> 08:21that Valve or the stomach and the esophagus.
08:23 --> 08:26So we're looking for signs of inflammation.
08:26 --> 08:28We call that esophagitis
08:28 --> 08:30or a Barretts esophagus,
08:30 --> 08:33which is that cell type that's acid
08:33 --> 08:35resistant growing upwards from the stomach.
08:35 --> 08:37And then also most importantly,
08:37 --> 08:41we then can take biopsies if there's a
08:41 --> 08:44Barretts esophagus to make sure there's
08:44 --> 08:47no dysplasia or precancerous change.
08:47 --> 08:50And so the population that seems
08:50 --> 08:54to benefit the most from screening
08:54 --> 08:56for Barrett's esophagus includes
08:56 --> 08:59people with chronic reflux, age
08:59 --> 09:02over 50 in the case of Barretts,
09:02 --> 09:02males,
09:02 --> 09:07more common than females and more common
09:07 --> 09:10in those who are Caucasian versus when
09:10 --> 09:13we talked about squamous cell cancer.
09:13 --> 09:14We see that more commonly in
09:14 --> 09:16regions of Africa and Asia.
09:17 --> 09:20So just a couple of questions to clarify.
09:20 --> 09:23When you say chronic reflux,
09:23 --> 09:26how long does reflux need to go on
09:26 --> 09:30for it to be classified as chronic?
09:30 --> 09:32Or is it a matter
09:32 --> 09:34of more the frequency?
09:34 --> 09:36In other words, if you get heartburn,
09:36 --> 09:38you know once in a while,
09:38 --> 09:40you know after a large meal
09:40 --> 09:41that really doesn't count,
09:41 --> 09:43but if you get reflux every
09:43 --> 09:44day then that counts.
09:44 --> 09:47So can you kind of tell us what classifies
09:47 --> 09:49as chronic reflux.
09:49 --> 09:51And then for the people
09:51 --> 09:53who do fit that criteria,
09:53 --> 09:56who are over 50 who have chronic reflux,
09:56 --> 09:57how often should they be
09:57 --> 09:58getting an endoscopy?
09:59 --> 10:01Yeah, all very good questions.
10:01 --> 10:05And so for length of time as
10:05 --> 10:09sort of a general rule of thumb,
10:09 --> 10:13some medical organizations have
10:13 --> 10:16suggested five years or longer of
10:16 --> 10:18symptoms as defining chronic,
10:18 --> 10:19but you're right,
10:19 --> 10:21pretty much everyone we know if we eat
10:21 --> 10:23certain foods or drinks certain things
10:23 --> 10:25we're going to have reflux that evening.
10:25 --> 10:27So it's really looking at
10:27 --> 10:29the frequency as well, so
10:29 --> 10:31symptoms that are perhaps occurring
10:31 --> 10:34on a daily basis or several times
10:34 --> 10:38per week over five years or longer
10:38 --> 10:41period would certainly,
10:41 --> 10:43you know, raise concern.
10:43 --> 10:46And again this is where it gets
10:46 --> 10:49tricky is that in the esophagus you can have
10:50 --> 10:52significant regular reflux,
10:52 --> 10:54but it doesn't necessarily mean
10:54 --> 10:56you have actual tissue damage or
10:56 --> 10:58inflammation or that you're
10:58 --> 11:00going to have Barretts esophagus.
11:00 --> 11:04So even amongst those higher sort of
11:04 --> 11:07risk group to have Barretts esophagus,
11:07 --> 11:09it might only be about 20% of that
11:09 --> 11:11group that will ultimately have it.
11:11 --> 11:14And then another
11:14 --> 11:16sort of risk stratification is
11:16 --> 11:19that if there's at the initial
11:19 --> 11:21identification of Barrett's esophagus,
11:21 --> 11:23if there's no dysplasia
11:23 --> 11:24or precancerous change,
11:24 --> 11:28the risk is very low and so that's
11:28 --> 11:29a very important distinction.
11:30 --> 11:32The medical term for precancerous changes
11:32 --> 11:35is dysplasia and we can grade that
11:35 --> 11:37as lower and high grade and if that's
11:37 --> 11:39present then we now have technology
11:39 --> 11:41through the scope to kind of ablate
11:41 --> 11:43the lining of the Barretts esophagus
11:43 --> 11:45in a very controlled fashion.
11:45 --> 11:47So with a series of scope procedures
11:47 --> 11:50we could actually convert that Barrett's
11:50 --> 11:52lining back to a normal lining in
11:52 --> 11:55most cases and about 80% of the time.
11:55 --> 11:56But it's really only worth
11:56 --> 11:59doing that if there's dysplasia
11:59 --> 12:00without precancerous change,
12:00 --> 12:02the Barretts is so low risk
12:03 --> 12:05it's not really beneficial to pursue
12:05 --> 12:07that series of scope procedures and
12:07 --> 12:10then if no dysplasia with the Barretts,
12:10 --> 12:11we would repeat the scope in
12:11 --> 12:13roughly three to five years.
12:13 --> 12:16So getting back to one of the things
12:16 --> 12:19that you mentioned at the top of the show,
12:19 --> 12:21which is that there's these two forms,
12:21 --> 12:23right, the squamous cell carcinoma
12:23 --> 12:25and the adeno and the Barretts is
12:25 --> 12:27really more in that latter group.
12:27 --> 12:30But the squamous tends to be really
12:30 --> 12:33frequent in parts of Asia and Africa.
12:33 --> 12:34And you mentioned that there were
12:34 --> 12:36a number of reasons for that,
12:36 --> 12:39smoking and alcohol and poor nutrition.
12:39 --> 12:42So couple of questions on that.
12:42 --> 12:43If people are in the US,
12:43 --> 12:45but they smoke and they drink,
12:45 --> 12:48and maybe they have poor nutrition as well,
12:48 --> 12:49there are plenty of food
12:49 --> 12:51deserts in this country too,
12:51 --> 12:54are they at risk of squamous cell carcinoma?
12:54 --> 12:57And if so, does screening apply to them too?
12:57 --> 13:00And the second part of the question is,
13:00 --> 13:02is there a genetic link for
13:02 --> 13:04esophageal cancers that might make
13:04 --> 13:07this more common in certain parts
13:07 --> 13:09of the world rather than in the US?
13:10 --> 13:12Yes, very interesting.
13:12 --> 13:15And as you know well
13:15 --> 13:17these themes kind of show up in many
13:17 --> 13:19different sort of cancer questions
13:19 --> 13:21across different types of cancers.
13:21 --> 13:26So it seems to be multifactorial that
13:26 --> 13:29there is some genetic predisposition
13:29 --> 13:32towards either getting
13:32 --> 13:34squamous cancer versus
13:34 --> 13:38the adenocarcinoma and then also
13:38 --> 13:40some behavioral or environmental
13:41 --> 13:42exposures as well.
13:42 --> 13:44So like we see in other settings
13:44 --> 13:45like colon cancer,
13:45 --> 13:47when you move say from one country
13:47 --> 13:49like Japan and the United States,
13:49 --> 13:52your cancer profile shifts.
13:52 --> 13:55So there are some dietary and
13:55 --> 13:57environmental exposures that likely
13:57 --> 13:59are a factor and that are often
13:59 --> 14:02very difficult to kind of tease out
14:02 --> 14:05exactly what are the greatest factors in
14:05 --> 14:08addition to a genetic predisposition,
14:08 --> 14:10but one thing that's interesting that
14:10 --> 14:13has been identified in studies for
14:13 --> 14:16squamous cell cancer in Africa and Asia is
14:19 --> 14:22the practice of drinking very hot
14:22 --> 14:25liquids often drinking frequent very
14:25 --> 14:28hot tea is part of the culture and
14:28 --> 14:31and that's been thought to irritate
14:31 --> 14:33the esophagus and stress the esophagus.
14:33 --> 14:36So that's an interesting environmental
14:36 --> 14:39sort of cultural factor as well.
14:40 --> 14:42Well, we're going to pick
14:42 --> 14:43up this conversation right after we
14:43 --> 14:45take a short break for medical minute.
14:45 --> 14:47Please stay tuned to learn more about
14:47 --> 14:49esophageal cancer with my
14:49 --> 14:51guest doctor Harry Aslanian.
14:52 --> 14:54Funding for Yale Cancer Answers
14:54 --> 14:56comes from Smilow Cancer Hospital,
14:56 --> 14:57where their cancer genetics and
14:57 --> 15:00prevention program includes a colon cancer
15:00 --> 15:02genetics and prevention program that
15:02 --> 15:03provides comprehensive risk assessment,
15:03 --> 15:06education, and screening.
15:06 --> 15:09Smilowcancerhospital.org.
15:09 --> 15:11There are many obstacles to
15:11 --> 15:12face when quitting smoking,
15:12 --> 15:15as smoking involves the potent drug nicotine.
15:15 --> 15:17Quitting smoking is a very
15:17 --> 15:18important lifestyle change,
15:18 --> 15:20especially for patients
15:20 --> 15:21undergoing cancer treatment,
15:21 --> 15:24as it's been shown to positively
15:24 --> 15:25impact response to treatments,
15:25 --> 15:27decrease the likelihood that patients
15:27 --> 15:29will develop second malignancies,
15:29 --> 15:31and increase rates of survival.
15:31 --> 15:33Tobacco treatment programs are currently
15:33 --> 15:35being offered at federally designated
15:36 --> 15:37Comprehensive cancer centers such
15:37 --> 15:39as Yale Cancer Center and Smilow
15:39 --> 15:40Cancer Hospital.
15:40 --> 15:43All treatment components are evidence
15:43 --> 15:45based and patients are treated with
15:45 --> 15:48FDA approved first line medications as
15:48 --> 15:50well as smoking cessation counseling
15:50 --> 15:53that stresses appropriate coping skills.
15:53 --> 15:55More information is available
15:55 --> 15:56at yalecancercenter.org.
15:56 --> 15:59You're listening to Connecticut public radio.
16:00 --> 16:02Welcome back to Yale Cancer Answers.
16:02 --> 16:03This is doctor Anees Chagpar and
16:03 --> 16:05I'm joined today by my guest,
16:05 --> 16:06Doctor Harry Aslanian.
16:06 --> 16:09We're learning about the care of patients
16:09 --> 16:12with esophageal cancer in honor of
16:12 --> 16:14esophageal cancer Awareness Month.
16:14 --> 16:16Now before the break, Harry,
16:16 --> 16:19you were telling us about two
16:19 --> 16:21different kinds of esophageal cancer,
16:21 --> 16:22squamous cell carcinoma,
16:22 --> 16:25which tends to be very common in
16:25 --> 16:27Asia and Africa, and adenocarcinoma,
16:27 --> 16:30which tends to be more frequent
16:30 --> 16:35here in the US, often caused by
16:35 --> 16:37Gastroesophageal reflux,
16:37 --> 16:42which can lead to this precancerous
16:42 --> 16:45lesion with dysplasia found
16:45 --> 16:47in Barrett's esophagus.
16:47 --> 16:49So when you were telling us a
16:49 --> 16:51bit about Barrett's esophagus,
16:51 --> 16:54you started to tell us a bit more
16:54 --> 16:57about how this could be treated
16:57 --> 17:00endoscopically such that you can
17:00 --> 17:02actually ablate the lining of that
17:02 --> 17:05Barrett and turn it back into normal.
17:05 --> 17:07I was wondering if you could
17:07 --> 17:10tell us a little bit more about
17:10 --> 17:12that and whether in fact do those
17:12 --> 17:14patients in whom you do ablate,
17:14 --> 17:15is there risk,
17:15 --> 17:17does their risk go back to baseline?
17:18 --> 17:20Yeah, it's been an
17:20 --> 17:21exciting development for us.
17:21 --> 17:23We have very highly calibrated
17:23 --> 17:26tools now that can ablate the
17:26 --> 17:28thin mucosal lining which is the
17:28 --> 17:30inner surface of the esophagus, with
17:30 --> 17:34just enough energy called radiofrequency
17:34 --> 17:36ablation to treat that without
17:36 --> 17:39damaging the wall of the esophagus.
17:39 --> 17:43And in about 80% of cases we can
17:43 --> 17:45remove the precancerous change
17:45 --> 17:48and also clear out all of the
17:48 --> 17:52Barrett's and the durability of those
17:52 --> 17:55treatments appears to be very good
17:55 --> 17:58where there's only about 2% per
17:58 --> 18:02year recurrence of Barretts and it's
18:02 --> 18:04typically non dysplastic barriers
18:04 --> 18:07that can just be a retreated.
18:07 --> 18:14So this rate of conversion has been very
18:14 --> 18:18reliable and very safe and long lasting.
18:19 --> 18:21Now, not all patients will present
18:21 --> 18:24with Barretts. At the top of the show
18:24 --> 18:27you were mentioning that
18:27 --> 18:29esophageal cancer is one of these
18:29 --> 18:32that's really tricky in the sense
18:32 --> 18:34that if you don't have symptoms
18:34 --> 18:36or you have things like reflux,
18:36 --> 18:39many of us get that and it has
18:39 --> 18:42nothing to do with esophageal cancer.
18:42 --> 18:43Unless
18:43 --> 18:44it leads to something like
18:44 --> 18:46Barretts and dysplasia.
18:46 --> 18:49And so oftentimes patients may present
18:49 --> 18:52late with symptoms like I can't swallow.
18:52 --> 18:55So in those patients who
18:55 --> 18:58go to their doctor because they're
18:58 --> 19:00having difficulty swallowing.
19:00 --> 19:02And they have a scope test which finds
19:02 --> 19:06a mass as opposed to simply a little
19:06 --> 19:08bit of dysplasia that you can ablate.
19:08 --> 19:11One would think that the treatment of
19:11 --> 19:13those cancers is a little bit different.
19:13 --> 19:13Is that right?
19:14 --> 19:19Yes, so the the sort of warning signs
19:19 --> 19:22of something more serious like
19:22 --> 19:23you mentioned difficulty swallowing
19:23 --> 19:25is something that you would
19:25 --> 19:28want to be aware of and talk to
19:28 --> 19:29your doctor about very promptly.
19:29 --> 19:32And other signs would be bleeding.
19:32 --> 19:34So bleeding from the esophagus or
19:34 --> 19:36stomach typically would present as
19:36 --> 19:38very dark black stools because the
19:38 --> 19:40blood gets digested by the stomach
19:40 --> 19:41acid and then turns a very dark
19:41 --> 19:44color as it passes out through the
19:44 --> 19:47Colon and through the bottom and
19:47 --> 19:51also weight loss would be another
19:51 --> 19:54concerning symptom or vomiting
19:54 --> 19:57or feeling like food is getting
19:57 --> 19:59stuck or having to regurgitate food.
19:59 --> 20:02So these are all signs of something larger
20:02 --> 20:05that could be blocking the esophagus.
20:05 --> 20:08And early detection as in many other
20:08 --> 20:11cancers is very important because we know
20:11 --> 20:15that the earlier stages have much better
20:15 --> 20:18treatment options and much better chance of
20:18 --> 20:23a curative and long-lasting therapy.
20:23 --> 20:25So endoscopy is the mainstay of
20:25 --> 20:28the initial sort of assessment and
20:28 --> 20:32diagnosis of these kinds of symptoms.
20:32 --> 20:35And so we can
20:36 --> 20:38very comfortably pass a scope through
20:38 --> 20:41the mouth under anesthesia and examine
20:41 --> 20:44the lining of the esophagus and the
20:44 --> 20:46stomach and then get biopsies of
20:46 --> 20:49the esophagus and stomach.
20:49 --> 20:53And then if there is a growth or tumor
20:53 --> 20:56in the esophagus or upper stomach,
20:56 --> 20:59we use a combination of tools
20:59 --> 21:01like in other cancers.
21:01 --> 21:04CAT scans to determine and make
21:04 --> 21:06sure that none of the cancer cells have
21:06 --> 21:08spread to other areas around the body.
21:08 --> 21:11And then we use this combination
21:11 --> 21:12of ultrasound and endoscopy
21:12 --> 21:14called endoscopic ultrasound,
21:14 --> 21:16where we do an ultrasound right
21:16 --> 21:19inside the esophagus and right next
21:19 --> 21:21to the tumor and we determine how
21:21 --> 21:23deep into the wall the tumor goes.
21:23 --> 21:25We call that at stage.
21:25 --> 21:27And then we determine if there's
21:27 --> 21:28any lymph nodes that look like
21:28 --> 21:30they're involved with cancer,
21:30 --> 21:32which is the end stage.
21:32 --> 21:34We call that local staging,
21:34 --> 21:38and the depth that the cancer goes
21:38 --> 21:42into the esophageal wall determines the
21:42 --> 21:44stage and determines what treatments
21:44 --> 21:47would be most effective and appropriate.
21:47 --> 21:49If we catch something really early
21:49 --> 21:51where it's just sitting on the
21:51 --> 21:52mucosal surface more and more,
21:52 --> 21:55we can treat those very early
21:55 --> 21:57cancers right through the scope
21:57 --> 21:59where we can cut them out.
21:59 --> 22:01Either by placing a band
22:01 --> 22:03around the tissue and grabbing it
22:03 --> 22:04away from the wall and cutting it,
22:04 --> 22:09or a specialized technique that we can
22:09 --> 22:11perform called endoscopic submucosal
22:11 --> 22:14dissection or ESD where we cut around
22:14 --> 22:16the cancer and then cut underneath
22:16 --> 22:19it to separate it from the wall.
22:19 --> 22:22But as the cancer grows deeper into the wall,
22:22 --> 22:23there's a fat layer and a
22:23 --> 22:25muscle layer below the mucosa.
22:25 --> 22:29Then it requires more extensive therapy.
22:29 --> 22:30So if it's
22:30 --> 22:32very early just into the wall,
22:32 --> 22:34then surgery can be pursued and as
22:34 --> 22:37it goes through the wall or spreads
22:37 --> 22:38to other areas then typically
22:38 --> 22:41a combination of radiation and
22:41 --> 22:42chemotherapy is pursued
22:42 --> 22:45and then after the tumor is shrunken,
22:45 --> 22:48which is can be done very effectively
22:48 --> 22:50with those medications then surgery
22:50 --> 22:52is considered to remove that area.
22:53 --> 22:55And so with that surgery,
22:55 --> 22:57would that surgery at that point
22:57 --> 22:59be done through a scope or would
22:59 --> 23:01that mean a bigger operation?
23:02 --> 23:06Yes, that surgery is done most
23:06 --> 23:10typically by thoracic surgeons and
23:10 --> 23:13it involves cutting out the affected
23:13 --> 23:16piece of the esophagus and they
23:16 --> 23:18do a special kind of lengthening
23:18 --> 23:21procedure to pull up the stomach
23:21 --> 23:24and connect it up to the esophagus
23:24 --> 23:29higher up in the in the chest.
23:29 --> 23:31So it's in expert hands
23:31 --> 23:34the outcomes are very good,
23:34 --> 23:36but it's a rather large operation.
23:37 --> 23:40Yeah, it certainly sounds like it would
23:40 --> 23:42be a lot better to catch this early
23:42 --> 23:45and have what sounds like a fairly
23:45 --> 23:47minor surgery done through the scope.
23:47 --> 23:51Would that be like a day surgery?
23:51 --> 23:54Do you even have to stay in hospital
23:54 --> 23:56after you do one of these
23:56 --> 23:59resections through the scope?
23:59 --> 24:01Yeah, most commonly we're able to
24:01 --> 24:03send people home the same day.
24:03 --> 24:05Occasionally we'll observe someone
24:05 --> 24:07overnight in the hospital, but
24:13 --> 24:15it is very remarkable how
24:15 --> 24:18the necessary treatment
24:18 --> 24:21changes as the cancer becomes more
24:21 --> 24:24involved and and grows deeper.
24:24 --> 24:26So talk a little bit about how you
24:26 --> 24:28really evaluate these lymph nodes.
24:28 --> 24:30I mean one can understand that if you
24:30 --> 24:33have a scope and you put it down the
24:33 --> 24:35esophagus and you see the little cancer,
24:35 --> 24:38you can take it out or ablate it or resect it.
24:41 --> 24:43But the lymph nodes aren't in the esophagus,
24:43 --> 24:46so how do you really assess them and how
24:46 --> 24:49do you tell whether those harbor cancers?
24:49 --> 24:51So many of our listeners may be familiar
24:51 --> 24:53with other kinds of cancers where you
24:53 --> 24:56actually need to kind of look at those
24:56 --> 24:58lymph nodes and often take a biopsy
24:58 --> 25:00to know that those aren't involved.
25:00 --> 25:02How does that work in esophageal cancer?
25:03 --> 25:08Lymph nodes, as you know,
25:08 --> 25:10live in various spots throughout the
25:10 --> 25:12body and they're kind of like filters
25:12 --> 25:14for different regions of the body.
25:14 --> 25:18So when we get like a sore throat,
25:18 --> 25:20your doctor might feel your neck to
25:20 --> 25:22see if there's any swollen lymph nodes.
25:22 --> 25:24And so those lymph nodes are always there.
25:24 --> 25:26But if they're swollen and enlarged,
25:26 --> 25:29they're reacting to something.
25:29 --> 25:32And that often is inflammation
25:32 --> 25:33due to an infection.
25:33 --> 25:37Or sometimes they they can be responding
25:37 --> 25:40to the spread of cancer cells and so
25:40 --> 25:43that often is a challenge throughout
25:43 --> 25:46cancer staging is to determine,
25:46 --> 25:49how do we know if cancers in
25:49 --> 25:51these might be very microscopic amounts
25:51 --> 25:54of cells that have traveled from the site of
25:54 --> 25:56the original cancer and then have sort
25:56 --> 25:58of been filtered by a lymph node nearby.
25:58 --> 26:00So in esophageal cancer
26:00 --> 26:03when we use the ultrasound
26:03 --> 26:05probe at the tip of the scope,
26:05 --> 26:07we can see through the wall of the
26:07 --> 26:09esophagus and we can see the surrounding
26:09 --> 26:11structures and those include lymph nodes.
26:11 --> 26:15So we look at the node and as it gets larger,
26:15 --> 26:17darker or rounder on ultrasound,
26:17 --> 26:19then we become concerned that it
26:19 --> 26:21may be involved with the cancer and
26:21 --> 26:24in some cases we can do a biopsy
26:24 --> 26:26right through the ultrasound scope.
26:26 --> 26:28We can pass this flexible long
26:28 --> 26:30needle through the scope and then
26:30 --> 26:32safely pass it through the wall of
26:32 --> 26:34the esophagus and stomach to get
26:34 --> 26:35samples of lymph nodes.
26:35 --> 26:38We don't typically do that for lymph
26:38 --> 26:40nodes right next to the cancer
26:40 --> 26:42because we wouldn't be able to tell
26:42 --> 26:44if the cancer cells came from the
26:44 --> 26:46primary tumor or from the lymph node.
26:46 --> 26:48But if there's lymph nodes further
26:48 --> 26:50away from the cancer,
26:50 --> 26:54then we can directly sample them in other
26:54 --> 26:57Imaging modalities like CAT scan,
26:57 --> 26:59they also look for the size and
26:59 --> 27:01features of lymph node and then
27:01 --> 27:03there's pet scans that look at the
27:04 --> 27:06sort of metabolic activity of the
27:06 --> 27:08lymph nodes and as it gets very
27:08 --> 27:11active can also help distinguish
27:11 --> 27:12between inflammation and cancer.
27:14 --> 27:16How often do we do cat scans and PET
27:16 --> 27:19scans and so on in esophageal cancer
27:19 --> 27:22to look at distant metastatic disease?
27:22 --> 27:24Yeah, it's very important
27:24 --> 27:27as part of the initial staging.
27:27 --> 27:31And so the accuracy of that initial
27:31 --> 27:34staging is very important so that we
27:34 --> 27:36can fit the treatment to the problem.
27:36 --> 27:38So we don't want to under treat,
27:38 --> 27:40we don't want to over treat.
27:40 --> 27:44So that initial staging including CAT scans,
27:44 --> 27:47sometimes PET scan for esophageal
27:47 --> 27:51cancer will almost always do that
27:51 --> 27:53endoscopic ultrasound as well.
27:53 --> 27:56And then from there,
27:56 --> 27:59we work as a multidisciplinary team
27:59 --> 28:02with the radiologist who look at the scans,
28:02 --> 28:02the pathologists,
28:02 --> 28:04who look at the biopsies,
28:04 --> 28:07the surgeons and the oncologist and
28:07 --> 28:10the radiation oncologist and then
28:10 --> 28:12make a treatment plan and then
28:12 --> 28:15once the treatment begins then
28:17 --> 28:19the oncologists typically would
28:19 --> 28:22have a set protocol where they'll
28:22 --> 28:25get periodic scans as the
28:25 --> 28:26treatments progress and then again
28:26 --> 28:28once the treatment is completed.
28:29 --> 28:31Doctor Harry Aslanian is a professor
28:31 --> 28:33of medicine and director of endoscopic
28:33 --> 28:36ultrasound at the Yale School of Medicine.
28:36 --> 28:38If you have questions,
28:38 --> 28:40the address is canceranswers@yale.edu,
28:40 --> 28:43and past editions of the program
28:43 --> 28:45are available in audio and written
28:45 --> 28:46form at yalecancercenter.org.
28:46 --> 28:49We hope you'll join us next week to
28:49 --> 28:51learn more about the fight against
28:51 --> 28:52cancer here on Connecticut Public Radio.
28:52 --> 28:55Funding for Yale Cancer Answers is
28:55 --> 28:57provided by Smilow Cancer Hospital.

Information

Esophageal Cancer Awareness Month with guest Dr. Harry Aslanian March 26, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095