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Making Strides in Esophageal Cancerby Don Norwood
In March 2006, esophageal cancer became a hot topic of conversation in Texas when former governor Ann Richards announced that she had the disease and would undergo treatment at The University of Texas M. D. Anderson Cancer Center. When Richards died of the disease only six months later, the hard facts about the high mortality rate of esophageal cancer came into focus. The National Cancer Institute predicted that about 14,550 new cases of esophageal cancer would be diagnosed in 2006 and that 13,770 patients would die of the disease the same year, making esophageal cancer one of the most lethal types of cancer. Although the prognosis remains bleak, advances in treatment have contributed to major improvements in both survival rates and survival duration in patients with esophageal cancer since 1970. M. D. Anderson Cancer Center has contributed to that improvement, as a multidisciplinary team of surgeons, oncologists, radiologists, and basic scientists has made great strides in the treatment of this disease. “We emphasize a multimodality, multidisciplinary approach here at M. D. Anderson,” said Wayne Hofstetter, M.D., director of the Esophageal Surgery Program and an assistant professor in the Department of Thoracic and Cardiovascular Surgery. “We’ve been at the forefront of that for the last 15 years. We really believe in the multidisciplinary approach because we’ve been able to attain a complete resection in a significantly higher number of patients through a careful combination of chemotherapy, radiation, and surgery.” Major improvements in survival rates and duration The numbers in an important 30-year study performed at M. D. Anderson bear out Dr. Hofstetter’s assertion. In that study, Stephen Swisher, M.D., a professor in the Department of Thoracic and Cardiovascular Surgery and the previous director of the Esophageal Surgery Program, looked at patients who underwent surgery for esophageal cancer from 1970 to 2001. As surgical techniques improved over that 30-year span, the 3-year survival rate increased from 27% to 46%. Furthermore, the median survival duration rose from 17 months to 34 months. Finally, the complete resection rate increased from 76% to 95%. Those amazing numbers reflect not only a better selection of candidates for surgery but also the constant advancement in therapy for esophageal cancer at M. D. Anderson. Specifically, they reflect the effect of teamwork among the different disciplines on treatment outcomes. “Things that are offered here that aren’t necessarily offered elsewhere are the innovative chemotherapy and radiation modalities in combination with surgery,” Dr. Hofstetter said. “In terms of surgical therapy, we’ve developed ways of performing surgery more safely. We have incredibly low mortality rates of 2% to 4%, even in patients who have had chemotherapy and radiation. Many cancer centers won’t perform surgery after chemotherapy and radiation because they consider it too difficult or risky. Preoperative chemotherapy and radiation therapy may make surgery more difficult, but we’ve been able to compensate for that with the experience that comes from being a high-volume center in surgery and perioperative care.” Another major development has been the opening of the Proton Therapy Center in September 2006, which gives patients with esophageal cancer treatment options offered in few other places. In fact, the first patient to ever receive proton beam therapy for esophageal cancer did so at M. D. Anderson. According to Dr. Hofstetter, proton beams target less normal tissue than other types of beams, allowing radiation oncologists to give higher doses to tumors and minimize the side effects to the surrounding healthy tissue. Current trials should help evaluate how well the technology meets expectations and add to oncologists’ volume of experience using proton beams against esophageal cancer. An insidious disease The question remains, though: why is this cancer so lethal? The fact is that esophageal cancer is a very insidious disease. By the time symptoms appear, the primary tumor is local-regionally advanced; thus, the patient is often not a candidate for surgery. Dr. Hofstetter compared it to pancreatic and lung cancer, both of which are considered “silent killers.” “Esophageal cancer often doesn’t become evident until it produces symptoms,” said Dr. Hofstetter. “The patient may have difficulty swallowing. There may also be bleeding, anemia, or black stools, and there can be pain. By the time these symptoms come up, the tumor is usually locally advanced.” Dr. Hofstetter uses an analogy to explain the extent of esophageal cancer to his patients. He compares the wall of the esophagus to the wall in a house. Superficial lesions occur in the “paint” layer of the wall and are easily cured by scraping this layer and possibly the “drywall.” However, more advanced lesions go through these layers and invade the nerves, lymphatic system, and blood vessels. “The lesion has access then to travel along those pathways, and once it has metastasized, it becomes almost impossible to cure,” said Dr. Hofstetter. “To use the house analogy, if it’s just local, just in the wall, or if it’s just barely gotten into the studs without invading into the plumbing and electrical circuits of the entire house, then I can remove that wall and still have a chance of cure.” Understanding risk factors Of the two types of esophageal cancer, squamous cell carcinoma and adenocarcinoma, the squamous cell variety is associated primarily with intake of carcinogens, most notably tobacco and alcohol, whereas adenocarcinoma is associated with long-term gastroesophageal reflux disease (GERD) and Barrett’s esophagus. Thus, individuals who fall into either risk category are prime candidates for esophageal cancer screening, which consists of endoscopic evaluation of the esophagus. Adenocarcinoma is the prevalent form of esophageal carcinoma in the United States. However, Dr. Hofstetter noted that not everyone with esophageal adenocarcinoma fits the typical profile: middle-aged, white, male, and slightly overweight, with a history of GERD. That presents the next challenge in esophageal cancer: determining exactly who is at risk. “There’s definitely a biological component to it, and there’s got to be some way that we can more specifically filter out who’s at higher risk,” said Dr. Hofstetter. “Screening tests are based in part on the probability of the disease in the community, but with only 15,000 new cases of esophageal cancer in the country every year, it’s just not cost-effective to screen the entire population. It’s something we’re continuously working on: identifying the best candidates for screening. “What we’re studying in terms of early-stage cancer is doing earlier surveillance and following people who have the markers for esophageal cancer. There are a lot of people both on the basic science side and on the clinical side here at M. D. Anderson who are trying to figure out ways to catch the disease earlier.” Providing palliative care Another important area is preserving and even enhancing quality of life. The most common symptoms of esophageal cancer are problems swallowing and the resulting weight loss. The multidisciplinary efforts at M. D. Anderson again reap benefits in this area, resulting in improved nutrition and comfort for patients. “We have a very good palliative care program for patients,” said Dr. Hofstetter. “Chemotherapy does a very good job of opening up the esophagus, allowing patients to swallow better and maintain their weight better. We also have mechanical ways of opening the esophagus using stents, ablation, and other means. “A surgical form of palliation is putting in a feeding jejunostomy. Most of the time, when we first see patients, they can’t swallow, and they lose a lot of weight. The average person in the United States is a little bit overweight and can afford to lose 15, 20, 25 pounds, but that’s not true for everyone. And as patients continue to lose weight, their nutrition declines, and they can’t fight the cancer anymore. Poor nutrition equals a shortened life span. Therefore, surgically, we’ll put in a feeding tube so they can go on to get treatment or palliative care, which can help maintain their nutrition for the rest of their lives.” The treatment of and screening for esophageal cancer remain high priorities at M. D. Anderson. This is evident in the growing multidisciplinary efforts that are aimed at further reducing the mortality of this now high-profile disease. Dr. Hofstetter and colleagues have developed ways of more safely performing surgery for esophageal cancer.For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789. Other articles in OncoLog, January 2007 issue:
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