Esophageal Cancer - Overview and New Diagnosis

Artwork for podcast "So... It's Cancer."

Episode 2 • 17th July 2022 • "So... It's Cancer." • Paul Bryan Roach

paul_roach:

Hey everybody, welcome to So Doc, It's Cancer, a podcast to understand cancer, how it happens, how it's treated, how we arrive at a diagnosis and at a prognosis, cancer's impact upon a person's quality of life, and how to move forward in life after a cancer diagnosis. The show airs monthly and we welcome your engagement and feedback. It's three cancer specialists and a graphic design artist discussing cancer. So I'd like to introduce our other hosts. First, I'll start with Peter Schlegel.

peter_schlegel:

Well, it's an honor to participate in this podcast. I'm an experienced oncologist and I've had lots of experience having talks with people at various stages of cancer. And I treasure the ability to communicate and hope that this is an opportunity for the audience to learn more about cancer and what it actually means without giving a medical school lecture.

paul_roach:

All right, and next is Mike Reardon.

michael:

Hello everybody In the lead-in I was described as a graphic design artist, which just means that I have no medical background I am here to keep the doctors honest I am here as the everyman or I wanted to be listed as schmo,

paul_roach:

michael:

but

paul_roach:

michael:

Paul Overrode me on that but that's my job

paul_roach:

You're the normal guy. And

michael:

I'm the normal guy

paul_roach:

Courtney, Courtney Koch, MD. Oh, I think we lost Courtney. Yeah, the screen's frozen. All right, well,

michael:

Hahaha

paul_roach:

hey, Peter, can you just tell us, and then I'm Paul Roach, I'm a surgical oncologist, and I just wanna convince these guys to join us. Peter, can you tell us just a little bit about yourself, tell the audience who you are and how

michael:

Hang

paul_roach:

you

michael:

on,

paul_roach:

decided

michael:

Paul.

paul_roach:

michael:

I'm

paul_roach:

get

michael:

going to

paul_roach:

into

michael:

jump

paul_roach:

oncology?

michael:

in. Courtney's moving on my screen. I think he's back. Give him a chance to introduce himself. Well, I guess not. My dad.

paul_roach:

Yeah.

michael:

Oh, he's moving.

courtney_coke:

Sorry about that guys, I'm Courtney Koch, radiation oncologist. Glad to be here. I live down the street from my buddies Michael and Paul and on the other side of the country from Peter. So I treat cancer patients with radiation. Been doing this for 25 years. We're happy to share my knowledge with everybody and to guide you along this journey or answer any questions that you have about cancer or about radiation treatments.

paul_roach:

Alright great, now one thing I'd like to do just to get things rolling is if each guy would just tell a little bit about yourselves, you know, just so people listening can know who's talking to them. So Courtney, since you're on the mic, would you mind just saying just a little bit about you know, yourself, where you grew up and where you went to school and how you got interested in medicine and in cancer.

courtney_coke:

So I was born in London, grew up in Jamaica on a farm in Jamaica. We'll talk about that sometime.

paul_roach:

That's all so normal, but yeah, go ahead.

courtney_coke:

I went to school here in Chicago, you know, I said Chicago and then at WashU. That's where I did my medical school training. Got involved in radiation oncology as with a lot of things in life. depends on mentorship. I had some excellent teachers who invited me to spend some time with them when I was in medical school, explore the field of oncology, specifically radiation oncology. felt as if it was something that I could do and decided to pursue it. And it's, I've never looked back. It's something that I take great pride in, to be able to be there for patients at very vulnerable stages of their life. Not everybody can do it, but it's an honor to be here for my patients. And I live in Chicago with my wife and two kids.

paul_roach:

Alright, alright.

michael:

awesome.

paul_roach:

Pete, you're

peter_schlegel:

Yeah, I have

paul_roach:

up.

peter_schlegel:

a pretty typical story. I grew up in the Midwest in the suburbs of Chicago, went to a Big Ten college, went to Rush Medical College, and went out to Utah to become a doctor. And while I was at the University of Utah on the oncology award, I really fell in love with leukemia management and taking care of people with severe illness associated with cancer. And that led to a fellowship in hematology, which is the study of blood and cancer, the study of cancer. And that's basically how I became what I am. And over the last 20 years, I've been practicing mainly in Washington state and the Pacific Northwest. I've been mainly a community, private practice physician working at a major medical center. I've taken care of all sorts of cancer, from lung cancer to brain cancer to pancreatic cancer, taking care of a lot of blood disorders, anemia, bleeding disorders, clotting, and so forth. At this point in my career, I've changed to the Veterans Hospital Medical Center to take care of our prior servicemen who've been afflicted with cancer and blood disorders. I have a passion for... for cancer, both the science and just the people that are involved in it, whether it's my infusion nurses, schedulers, laboratory techs, or the patients actually experiencing this. We have access to tremendous science and knowledge. and opportunities for people. It is becoming increasingly more complex and additionally scary, but also more powerful in terms of the tools that we have. And I think this is gonna be a great opportunity just to talk about what we do as a unit. What's the difference between a radiation oncologist, a medical oncologist, a surgical oncologist. Talk about how people experience their cancer from the diagnosis to. to their treatment. My particular specialty is medical oncology, so we're using medicines and traditionally they've been chemotherapy, but over time we've evolved into using endocrine or hormonal therapy where we block estrogen or testosterone and targeted therapy which uses smart bombs rather than non-specific nuclear attacks. And over the last three to five years we've been using immunotherapy which adds tremendously to... our ability to fight cancer. Again, excited to be here today and to talk a little bit about medical oncology and what we, basically what our world is like.

paul_roach:

Awesome, awesome. And Mike, how did an honest guy like you get involved with this group of tufts over here? How do you get dragged into this?

michael:

Because I know you, Paul.

paul_roach:

Ha ha.

michael:

That's how that happened. Right, as I already said, I'm completely not, you know, it's a really tough crowd to follow all those qualifications. And then there's me, has nothing to do with this. I'm not a cancer patient. I'm not a cancer doctor. I haven't even watched a Dr. House or Dr. Marcus Welby MD in a long time. None of that. I got nothing, except again, just to be the voice. of the plain man. Plain man of

paul_roach:

That's

michael:

the people,

paul_roach:

perfect.

michael:

that's why Paul, that's why you chose me.

paul_roach:

That is awesome. That is awesome. And we love you for it. All right. And

michael:

paul_roach:

my name

michael:

ha.

paul_roach:

is Paul Roach. I grew up in Oak Park. I went to high school with Mike here. I went to med school with Pete at Rush. I live right down the road from Courtney. I went to... University of California for my internship, and University of Maryland for my residency in general surgery, and University of Chicago for my fellowship in surgical oncology. And I work in the VA as well, and I love taking care of my VA patients. All right, so let's move on. We'll move on to the next section. We don't have any guests today. I figured it's early in the program to start inviting people. But once we get our own stride going, we can start inviting guests. But today, we'll start off with case of the day. And I thought I'd start off this month. And I saw two of these patients as new consults last week. don't get to see too many of them ordinarily, so I thought it was a sign that maybe this is the first disease process that we discuss as a group. It was esophageal cancer. So what I'll present now is a fictitious case, just sort of a made-up one, intended to exemplify the situation. So let's say I have a 59 year old male. No known past medical history, which frequently means that they maybe don't see the doctor too much. And he's got progressive difficulty swallowing for about two months, really just to solids. Meat or chicken kind of stick in his chest. And so he's only been drinking liquids and having semi-solids like pudding or things like that. And he's had at least a 10 pound weight loss. comes to the doctor with that. He smokes about a pack and a half a day, and maybe he has one to three drinks per day. So since it's a cancer podcast, you know, Pete or Courtney or Mike, what would be your guess on what this guy's differential is? What options

michael:

What's

paul_roach:

michael:

paul_roach:

you

michael:

differential,

paul_roach:

think he's got?

michael:

Paul?

paul_roach:

Oh yeah, that's one we try to figure out. All right, of the various illnesses that a person could have, which ones do you think it could potentially be?

michael:

Oh I see, because he smokes and he drinks and he's got an age thing and... Okay,

paul_roach:

He's got food

michael:

so...

paul_roach:

sticking in his chest, yeah. Well, there's a variety of things it could be, but it could be esophageal cancer, maybe lung cancer, sort of sticking into the esophagus. There's other esophageal diseases which we'll skip, but let's just go with,

michael:

Well, wait, let me stop you there because I only know, you know, again, I know nothing, but if I'm, if I'm this guy and I'm having a hard time eating, I, I'm eating a box of Tums every day.

paul_roach:

Yes.

michael:

Right.

paul_roach:

Yeah.

michael:

I mean, I'm, I'm thinking I've got, I'm not, I probably wouldn't even come see you first. I probably went to see my regular doc and I'm thinking I've got, you know, like a eating disorder or what do you call it? a gastro... something.

paul_roach:

Like, yeah, I think that's a good point. I mean, Pete, how many times do you see somebody where they've been kind of treating themselves thinking it was something normal when it was

peter_schlegel:

Oh,

paul_roach:

actually?

peter_schlegel:

yeah, I think the point of the question is how they even wound up in your office and how we're even talking about a differential. How does a guy in the street who's saying, I've had a little difficulty swallowing and sure they're taking some pepsi or maybe they think they had a little food poisoning or they've been, you know, just it's not a big deal. And and then all of a sudden, they're not. Swallowing chicken they go get their favorite chicken and they have a bite of chicken breast they get stuck and their Gagging is a pretty terrible and friend looks empty. What the hell is going on and Say you need to get checked out. So the typical person would call their Primary care doc and say, you know, I kind of have some problems swallowing Can you check me out and the primary care doctor would say ask them questions? Have you lost anyway? Do you see any blood? Is it hurt right now or there's certain things? And anyway, the long and short is they isolate the symptoms to your esophagus and from there, the primary care doctor or whether it's an urgent care doctor, ER doctor, a friend who's a surgeon who they happen to know, they get referred on to generally a GI doc to get that checked out. You can do barium swallows as well, but generally they... Want to do a scope and the GI doctors were more than happy to stick a scope down and lo and behold boom There it is halfway down there. There's cancer now having said that nine out of ten times they they Do this they find that there's an ulcer in there. There's some sort of scar tissue. They have a infection something like that, but time but there's often more problems and say a cancer and the pathology at the GI doctor does the biopsy and says, wow, there's something bad there, I do some biopsies. And they wind up talking to the patient afterwards and chances are that the patient won't even remember because they're recovering from their anesthesia, but their spouse or driver said, well, they found something. And they're like, wow, we'll give you a call in a couple of days. And a couple of days later, they get a call from the doc and say, you know, it doesn't look good. It looks like cancer. cancer. And from there, then they call up and say, well, we got to get you into the world of cancer. And whether they call up a medical oncologist or a surgical oncologist, that's kind of when the ball gets rolling. But basically, we have to start somewhere and there's some suspicious symptom that draws the attention of the medical community. And that's basically what starts things rolling.

michael:

I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I-I

peter_schlegel:

It's a pretty critical

courtney_coke:

But you know,

peter_schlegel:

step

courtney_coke:

Paul,

peter_schlegel:

there.

courtney_coke:

I think it could also, given this patient's history, also be a head and neck cancer. Would present with the similar symptoms of the patient with a smoking history that has difficulty swallowing or dysphasia or pain on swallowing or dynaphasia.

michael:

Alright, I gotta cut in. What's dysphasia?

paul_roach:

No!

courtney_coke:

Difficulty swallowing.

michael:

Oh, OK.

courtney_coke:

would be dysphasia or a dynaphasia, which would be pain unswallowing, or it could be a large lung cancer that's pressing in the center part of the chest. So I think that those may also be possibilities. And as Peter said, that they would see their primary care physician and they would then look at their symptoms and refer them for the proper testing to get an idea of what that's, where things will lead to.

paul_roach:

So I'm thinking

michael:

So was the original

paul_roach:

like.

michael:

question, Paul, like, you want these two guys to guess? I'm ready to guess. I

paul_roach:

Alright,

michael:

think I know.

paul_roach:

alright. No, really. The question was meant to actually bring up

peter_schlegel:

Yeah.

paul_roach:

the discussion that we just had. The exact...

michael:

Oh,

paul_roach:

michael:

all

paul_roach:

knew

peter_schlegel:

Yeah.

michael:

right.

paul_roach:

they

michael:

I thought

paul_roach:

are,

michael:

that

paul_roach:

michael:

paul_roach:

knew

michael:

was

paul_roach:

you

michael:

like...

paul_roach:

all already knew. But you know, kind of like step one, you know, a person has some sort of symptom which is pretty way out of ordinary. You know, how often is food sticking in your chest? Now, if it is sticking in your chest, that doesn't mean it's cancer. There's other things like esophageal webs or ulcers or other problems that can happen that cause it and that are a lot less. you know, scary than a cancer, but what we're talking about is when it is. So step one is you figure something is serious enough to go to your primary care doctor or if it's stuck in your chest and you're uncomfortable, you might go straight to the ER. And then step two, I think would be one man or a physician or another brings you to the attention of a GI doc. And they do... typically a scope like Pete said. And you swallow this fiber optic tube that has a little video cable on it and you can see everything on the TV screen. And it shows in the middle of your food pipe, a lot of distortion and altered anatomy. And then they'll take a little piece of it for analysis down in the lab. Couple days later, the laboratory comes back with the report, yeah, this is cancer. Then the next step is you have to work it up and figure out is this cancer local to the food pipe, to the esophagus, or has it begun to move outside of that area? That's called a staging workup. And it involves...

michael:

I'm just out of curiosity, how does that happen? What kind of test do I have to have if that's, what am I in for, how do they test for that, Paul?

paul_roach:

I think the first couple things you would do would be, one, it'd be a CAT scan. where it's a series of, it's like a, everyone I think is aware of what a CAT scan is nowadays, where it's just a series of x-rays that goes through your body, and you can look at every 2.5 centimeter slice of your body in all three dimensions. And so you can get a really good picture of your insides with this CAT scan. Another thing that you would get is called a PET scan. So cat and pet. I don't know how these names came this way, but a PET scan is a functional image. A CAT scan is an anatomic image. The PET scan looks for areas that are really metabolically active, and you can overlay that on the CAT scan. And so if there's a blob... on the CAT scan, a little area that doesn't look quite right and it's metabolically very active, you start to really worry that that could be part of a tumor. You may also do other studies like, it's another version of it. EGD, the scope, where instead of just looking with light, they put an ultrasound probe down your food pipe and it uses something like sonar to look in the immediate area around the esophagus and it can tell how thick the tumor is and it can tell if there's things in the immediate area that are abnormal. So that's a lot of work up, it's a lot of money, it's a lot of insurance money typically. It means that if you're not in a affluent nation, you're not really gonna get that kind of work up. But Pete and Courtney, how'd I do on describing that?

courtney_coke:

You did great. I think,

paul_roach:

Oh, thank you.

courtney_coke:

you know, you just, you earned your medical school degree right there, Paul.

peter_schlegel:

Yeah

courtney_coke:

No, I think, yeah, that's a staging workup. And that is such an important part of our care and standards of care, because that is how, for example, we are able to then, analyze patients and make sure that how we're treating patients is in keeping with all the studies and protocols because if all patients are getting the same type of workup, we can then put patients into stages and decide how to treat the patient based on the stage that they're in.

michael:

Oh, is this the stage one, stage two, stage three, stage four thing that you always hear about with

paul_roach:

Exactly.

michael:

cancer?

courtney_coke:

You

paul_roach:

Yeah.

courtney_coke:

got it.

michael:

So one is your early stage four is really bad, right? Or have I got that backwards or something?

paul_roach:

No,

peter_schlegel:

No,

paul_roach:

you got

peter_schlegel:

I think

paul_roach:

it right.

peter_schlegel:

that's an excellent way of looking at it. When I, as a medical oncologist, I'm going to look at it and be very objective and say what stage you have. But as a human being who's experiencing this illness, your first question is, you know, how bad is it, Doc? What can we do? And the doctor, the medical team, the cancer team needs to... know what's realistic and the stage determines the spread and then therefore the prognosis. If it's a little lump at stage one, we just call up our friendly surgeon Dr. Roach and get scheduled for surgery. If it's stage four, the cat's out of the bag, it's spread. The prognosis isn't so good. We may have treatments available, but the bottom line is the cat's out of the bag. It's incurable. We can slow it. down. The stage two and three is locally advanced and it gets pretty complicated to say well how deep it is, did it involve lymph nodes, and so we get into a minutia there. But the second question that the patient will generally have after is you know what kind of cancer is this cancer, next one is you know what can we do about it, and the doctor then has to look and say well it's localized we just need a surgeon or It's really pretty advanced and there are things we can do to slow it down. And then of course there's the gray area in between where it's not localized, it's not through the whole body, it's locally advanced and our radiation people become involved. And you unfortunately at that point have to involve all three of the cancer specialists. You need a surgeon, you need a radiation doctor, and a medical oncologist. And we all use... the tools we can to help to treat that patient, knowing that not one of us has the solution, but by combining our efforts together, that we give the patient the best chance of a good outcome.

michael:

I want to jump in again. I'm always jumping in, I'm sorry. So if I'm hearing this right, if I've got stage one, I'm likely to see Paul Roach here who is a surgeon. Because that's going to be the quickest, easiest thing is to go in and just cut out any tumor or anything that's in there if it's small enough and easy enough to get to. If it's stage two or three, I'm likely to see Courtney Koch, our radiation doctor. because it's going to require, as you said, it was more generally, it's still localized, but it's larger and a bigger problem. And then if it's three, four, is that when we see you, Peter?

peter_schlegel:

Yeah, I think the stage two, three, I would consider is locally advanced that the stage one is typically very localized. The chance of having fingers and spread to lymph nodes is fairly limited so that the treatment would just remove the tumor, get it out, and then you're done with it. Unfortunately,

michael:

Wait, when

paul_roach:

Well,

michael:

you say

paul_roach:

michael:

fingers,

paul_roach:

you're,

michael:

sorry.

paul_roach:

if you're, it gets a little more complicated. Like within stage one, there's one A and one B. And so if it's stage one A where it's really superficial, it's caught very, very early. uh... your gastroenterologist can just carve out the inner lining of your food pipe of your esophagus and you're treated successfully that way if it's 1B, if it's just a little bit deeper that's probably not going to work and that's where people start to go for removing the esophagus which is a really big deal it's in your neck, it's in the center of your chest, it's in your upper abdomen it's a big procedure stages two and three as well. Now for example, one of the patients I saw last week, he's going to get chemo and radiation therapy first, and then we're going to see if the thing shrinks enough to make surgery reasonable. What do you think of that Courtney?

courtney_coke:

You mean so-called neoadjuvant therapy?

paul_roach:

Yes.

courtney_coke:

Yeah, and

michael:

Wait, what was that? I missed that.

courtney_coke:

neoadjuvant therapy, therapy that's

paul_roach:

Sounds

courtney_coke:

given

paul_roach:

like something

courtney_coke:

before

paul_roach:

from The Matrix.

courtney_coke:

the surgery's done, that

paul_roach:

Yeah.

courtney_coke:

doesn't it? But I think that is a very reasonable approach for... some esophageal cancers and for other types of cancers, which we'll talk about in later podcasts, that approach is used because it allows shrinkage of the tumor and decrease in the likelihood of those finger-like projections that Pete is talking about. or of lymph nodes being positive if you're able to treat the tumor and the areas at risk around it before you do any surgery. So the surgery is more complete and more able to get a complete resection of any cancers. But getting back to what Pete was saying and the question you asked, Mike, I think for most stages radiation is never given by itself. unless you're doing something that you're not hoping to cure the person or it's for pain or what we call palliation. In most cases I would say radiation is going to be coupled with chemotherapy, either if you're giving it before the surgery or after the surgery I would say.

michael:

Well, you know what? Help me out here then. What's... Because again, no knowledge whatsoever. Chemotherapy, obviously chemo-chemicals, but I always kind of thought chemotherapy and radiation were sort of the same thing. Help me out. What am I getting wrong about that?

courtney_coke:

So with respect to the radiation treatments, they're x-rays, they come from a machine, like a regular x-ray machine that you would use to take an x-ray of a broken bone or a lung. It's controlled with an on and off switch and these high energy beam, this high energy beam comes out of the machine, we direct it to one part of the body. So it's very localized, very localized in most situations. and it's divided into days of treatment over a series of weeks typically. So it's localized treatment coming from a machine in the form of x-rays. The side effect profile is different and I'll leave Pete to talk about chemotherapy which is of course a more general treatment to your whole body.

michael:

Huh, okay.

peter_schlegel:

And so chemotherapy is a medicine that basically destroys cancer cells Whether it's in a localized field where it started or elsewhere in the body the idea is that we're selectively poisoning the cancer and That obviously is a good thing the the problem with chemotherapy is obviously the side effects and the fact that in many cases, it doesn't work as well as we'd like it, that it doesn't kill every last cell. It shrinks it, it stuns it, it puts it to sleep, but it doesn't kill it. So that's why we need to use everything we can to fight the cancer. Let me, if you don't mind, I just wanna back up and talk about cancer happen we've talked about stage and where it started but the story of the cancer is it starts there's usually some sort of irritation in the body inflammation that occurs in some sort of esophageal cancers it can be acid reflux year after year the redness from the the burn causes inflammation and inflammation causes mutation and that can lead to cancer. And that's a very common reason for esophageal adenocarcinoma, which is kind of the most common subset of esophageal cancer. Another subset of esophageal cancer is squamous cell and it's the irritant that leads to this. evolution or change to cancer is often smoking or tobacco. But in any case, we wind up with a cancer cell and it may be only one cell, but that cell becomes two, becomes four, becomes eight, and reproduces uncontrollably. And over time it finally presents itself. And whether that, when it shows itself, it's simply a lump in the esophagus and can be resected. Or whether it's had the ability to develop fingers and spread elsewhere. That's really what we're talking about for stage. Where exactly in its development it is. fairly early, you know, our outcomes are a lot better. However, if it festers, it develops fingers, eventually those fingers develop and break off and spread metastasized, then it's totally different. entity and becomes much harder to deal with. And so when we address the cancer, we talk about stage, but we also have to kind of understand what's actually going on. And then we can better pinpoint exactly what needs to be done and what are available tools to do that.

michael:

It kind of sounds like if I have Based on what you're talking about where there's an irritant that it's constantly sort of happening so if I'm a regular schmo and I have a Lot of acid reflux or I am eating a lot of Tums Or Rolade's or if I have a like a tickle or a scratch that won't go away this is the type of thing that I should actually not just ignore? Like what are some of the other things maybe that would get me into the hospital after I've listened to this podcast, I'm gonna say, oh, the doctors have told me I should pay attention to these small problems before they become big. So help me out, what are those things? So, I'm gonna say, oh, the doctors have told me I should pay attention to these small problems before they become big. So, I'm gonna say, oh, the doctors have told me I should pay attention to these small problems before they become big.

paul_roach:

I like that, I like that a lot. I think the, for esophagus or for esophageal carcinoma cancer, the two subtypes are the one that sort of happens as a consequence of mostly drinking and smoking in the Western culture. That's the squamous cell type and the other one is the one that happens as a result of acid reflux. that's the adenocarcinoma type. That one happens lower in the esophagus, the other one happens typically higher. It used to be that the drinking and smoking one was the most common, but now the acid reflux one is the most common. So I think if we're speaking to a Western audience, I think what you're talking about, if you're having a lot of reflux and it's going on for a while, reach out to your doctor because not only can you get your reflux symptoms improved by taking care of steps one two and three let's say but there's also always a low chance it's not a common cancer there's a low chance that you're gonna sort of lower the risk of developing this thing in the long run.

michael:

Okay, but it will present itself as I feel like I've got acidid digestion, or

paul_roach:

Yes.

michael:

I feel like I've got a tickle in the back of my throat, never goes away.

paul_roach:

I think that's pretty fair. It can be tricky. One of the things about cancer is it can sneak up. But a lot of times, I'll jump into this right now, the lesson of the day with esophageal cancer. So the next section is that it's currently the eighth most common cancer worldwide and the sixth most deadly. It's a... It's a cancer that moves pretty quickly and it's in the center of your body, in the center of your chest. It's most often diagnosed at a more advanced disease stage. So many times when you do finally get around to diagnosing it, and I think like you're describing, people live with symptoms for a long, long time without knowing, it might be kind of late. Not always, but it happens a lot. There's a variety of types, but there's two major ones, the adeno and the squamous cell. We've already talked about those. And these are very distinct, both in how they happen and where they're located in the food pipe, in the esophagus, whether down low by the stomach or up higher in your chest. Adeno is usually the lower third, and there's this precondition called Barrett's esophagus, which is a consequence of chronic reflux. These are the main risk factors associated with it. So if your doctor says, oh, you have Barrett's, first of all, that doesn't at all mean, oh my gosh, I'm going to get this cancer. There's different subtypes of Barrett's. There's short segment and long segment. There's a variety of different things. So not to panic, but definitely to manage it. but it's associated with a much higher risk overall of cancer. And then. with squamous cell it's this chronic irritation caused by tobacco smoke and heavy alcohol consumption. Now they're like Courtney had mentioned earlier those people are also going to have problems up higher in their throat and in their lungs as well. So if a person is a chronic smoker or drinker that they definitely need to be in touch with their primary care doctor more often and quicker over all these issues. What do you guys think?

michael:

Which one is gonna more likely be how we started the show, which was, I can't swallow.

paul_roach:

Oh, either one. Either one.

michael:

Oh, okay.

courtney_coke:

And that's an excellent question, Mike, because I think that's another presenting symptom. In fact, it's a very common presenting symptom. Patients that have progressive difficulty swallowing, that they find that they're trying to swallow food and it's just not going down right. And it may go from liquids to things that are softer and eventually progress to having difficulty swallowing solids. prompt someone to see a doctor would be a good take-home message for patients. I think another good take-home message is to make sure that you keep in very close contact with your primary care physician and you're following the guidelines for when you should have a scope. There's standard guidelines for that as to when you should they should actually look down as Paul said Just to see what your esophagus looks like if there's changes that are concerning As we'll discuss in the future podcasts to look down below in the anal and rectal area So I would encourage our listeners to just discuss that with their primary care physician and get a clear idea It's to be preventive, you know, when should I start this process of being? Um.

michael:

Well, that's interesting because once I hit 50, I'm old, once I hit 50, the doctor said, okay, you have to have a colonoscopy. And that was paid for by my insurance. And they said, this is preventative. No one's ever said go have a preventative esophageal scoping. Is that something that I should be asking for? Does that even exist like the way the colonoscopy is every 10 years? Is that a thing?

paul_roach:

Very good question. No, it's not. We can get into,

michael:

Well, why

paul_roach:

all

michael:

not, Paul?

paul_roach:

right, well, in a different episode, we'll do a deep dive into screening tests. But, for example, if we were in Japan, where the incidence of these cancers is higher and gastric cancers is higher, yes, you would get a screen. I am not. from Japan, I don't know that for a fact, but that's my understanding, is that because the incidence is much higher and they've got different ways of screening and they tend to catch these earlier because of the screening programs. But it's not as high, it's not as common a problem here in the USA, so screening programs like routine screening, everybody with the upper scope, they don't make sense here.

michael:

Wait, didn't you say this was the 7th most common cancer?

paul_roach:

worldwide.

michael:

Oh, we're not in the US.

paul_roach:

We'll do a deep

michael:

OK.

paul_roach:

dive on screening tests. But that is a complicated subject. It's a very good question.

michael:

Okay.

paul_roach:

We're going to have to put a pin in that

michael:

I will

paul_roach:

one.

michael:

be tuning in to that future episode.

paul_roach:

All right, so now

michael:

Keep

paul_roach:

michael:

paul_roach:

michael:

eye out

paul_roach:

section,

michael:

for it.

paul_roach:

next section, moving along is cancer questions. And this one came from my darling wife, Megan. And she said, how do you tell a patient that they've got cancer? So let's start with, let's start with Courtney.

courtney_coke:

I think that raises the question of referral. When I see patients, typically they already have the diagnosis.

paul_roach:

Oh yeah, of course,

courtney_coke:

But

paul_roach:

of course.

courtney_coke:

I think I can maybe speak about if a patient's cancer has progressed or there's something new that comes up where they are being treated and there's not... good progress at their treatment or something has recurred. I make sure it's face-to-face. I make sure that we have reviewed the records, which goes without saying, very thoroughly. And I also ask the patient, you know, try to work with our nursing staff. to work with the patient to make sure that there's some kind of support for the patient in that face-to-face encounter. And then I think there's no other way but just to encourage the patient and let the patient know that despite this setback, that we are experts in the field. We have a lot of tools that we can pull from and that... you know, we are going to use these tools to the best of our ability to properly stage the cancer it is right now and then to treat it.

paul_roach:

What about you, Pete?

michael:

I think we lost Pete's audio.

paul_roach:

Yeah.

peter_schlegel:

All

paul_roach:

Yeah.

peter_schlegel:

right. I agree with everything that Courtney said. What I would like to add is there's really no good way to tell someone they have cancer. Bad news, period. Bad news. You can sugarcoat it and say, you know, we got an excellent plan, we got a team, but the bottom line is you have cancer. And as human beings, when we hear bad news, we react. And are we in denial? Are we angry about it? we can go through a host of different emotions. But the long and short is that hearing the words that you have cancer hits the vast, vast majority of us like a ton of bricks. And the people who respond and say, well, it's just cancer, I'll deal with it. Those are the people that I worry about most psychologically. So the word cancer just starts a conversation in a very awkward manner. Now, having said that, We do, the patient who's been now diagnosed with cancer, that person has become a patient and they need to have a team, they need to have a doctor, they need to have a plan. And I think once the ball gets rolling and we learn more about it, that's gonna empower us to be able to treat it. We need to put a name on it, what sort of cancer is it? We need to identify, well, what's the extent? What's the spread? What's the stage? we can identify the people that are going to be necessary to help to treat this. Is it going to be surgery? Is it going to be a specialty surgeon? Is it going to be to be radiated? Is it to get some sort of systemic therapy? And then what is the prognosis and all that? But you know, the bottom line is there's no good way of saying it. You can sugarcoat it all you want or have a physician who sugarcoats it, but it's still cancer.

courtney_coke:

And I would add to that that it's part of the art of medicine is that we individualize our treatments and our approaches to patients because I think that people process trauma very differently, different people process trauma very differently. So one of the things that we all do in our offices is we do get an idea of what type of patient this is. And I think that... patients even though they're presented with a very traumatic situation, if you have a plan I think that's very reassuring to patients to know that this is the situation but we have a plan. This is how we plan on dealing

paul_roach:

Yeah,

courtney_coke:

with it

paul_roach:

yeah, I like that.

courtney_coke:

and to instill a sense of confidence so there isn't all this unknown and... uncertainty around the diagnosis, which is, as Pete says, it's bad enough as it is, but to give them a plan to move forward I think is very reassuring for patients also.

paul_roach:

I find as a surgeon, I have two categories. One is when the patients kind of are expecting it. You know, they've already been referred and they kind of know where we're headed. And then the other is when it's just a complete surprise. Like last week, I had a patient in the ER and this happens fairly... regularly where they came in with a new condition, and within a few minutes I'm having to tell them, this is probably cancer. And so that's an enormous shocker. But I agree with everything you guys are talking about. I don't know if there's a best way. I tend to bring it up pretty quickly because the patients... if they see you dancing around the subject, it only makes it harder for them. So it's better just to come out with it, I think. And then you can start talking about it. And Courtney, I think you said that the key is to have a good plan. So that they know, all right, we're in a tight spot here, but we've got this plan. And like Pete said, sort of bring to mind all the different things that we can bring to bear. here in the 21st century in Western cultures with respect to the five different types of medical treatments and the radiation treatment and the surgical treatments. I think that's my approach typically is to try to make it quick and then start listening to their questions. Because the other thing that I also warn everybody is like you're starting a college course on cancer million new concepts and terms and and all these things that you'll be learning and that was actually part of the genesis of this podcast is there's just so much to teach you can't get it done in a clinic visit.

michael:

You know what, I want to interject

paul_roach:

Yes,

michael:

again.

paul_roach:

sir.

michael:

My question is, you guys are conscientious medical professionals. What if for some reason, for whatever reason, my doctor in a big hurry comes in, just says, yeah, it's cancer, and he doesn't tissue, they do not present me with a plan. And I'm sitting there in kind of shock. How do I address that? How do I get a plan? How do I, if my doctor isn't forthcoming with that information, what do you suggest that I do in order to make that happen? How do I get a plan if one's not being presented to me? I don't know.

peter_schlegel:

Well, the most realistic option in a situation like that is call someone in the family who's or a friend who's allied with the medical profession. Nurses can be great, friends and family, I get calls quite a bit when stuff like that happens. It is basically a two-way street so that the provider does have an obligation to provide the patient, but sometimes that doesn't work. that are available but I would gather that somewhere along the line there's a connection that if you don't have a relationship with your primary care or that the bomb was dropped and you feel like you're totally stranded there you just need to start asking for help and I think that's really critical when you have cancer that you ask for help

paul_roach:

But you know,

peter_schlegel:

and

paul_roach:

I think...

peter_schlegel:

you're not going to be able to figure out yourself.

paul_roach:

I think Mike's point is really important. There's a big issue in... certainly in the cancer world and all the others, but in disparities in outcomes with cancer care, because there's a large segment of the population that really doesn't have access to someone on their, I can call list who might be able to give them good advice. So I think that that... question is really important for the system as a whole, because it works well for those for whom it works well. But there's a lot of people who are kind of left out, and when their doctor isn't knowledgeable enough, or they're not involved enough, or they don't have enough time, or... whatever and they say, all right, you've got cancer and you know, we can't do anything about it. How does a person know that really there isn't anything that can be done? And I don't have an answer for that yet. But that's an interesting problem. I'd love to say there's always going to be someone you can call. But I think the truth is sometimes you have to. I don't know, like in Chicago, I think we're gonna start. working on that problem more than we have been, trying to get cancer care out into the full community. Because I think there's a fair number of people who've been kind of left out of the best cancer treatment. I don't know if you guys, if I'm making sense or if I'm just sort of talking around it.

michael:

No, I mean you're basically saying that there are communities that the health care system doesn't fully serve. For either it's because of insurance, it's because of access to facilities, or it's because of whatever. How did, you know... And if they are being served at all, it may be overcrowded and the doctors may be busy. And that's kind of where my brain was when I was like, you know, what if you just kind of get breezed in, it's like, well, you have cancer. We'll make an appointment for you for two weeks from now. And that's all they tell you. So you're not giving that plan kind of thing. So I guess, yeah, it's like how do I get around that if that happens to me? How do I sort of force a plan? Or, you know, do I come back and say, well, I did my research? I listened to this great podcast

paul_roach:

Yeah.

michael:

with three doctors and a graphic

courtney_coke:

Mm-hmm

michael:

designer and I found out that these are some of the things that should be happening. Like, can I interject myself with you very intimidating doctor types and feel like I can get heard?

courtney_coke:

I think what we're also saying, Mike, is to use the support systems that are around you. And as Pete and Paul are saying, that may involve a friend, it may involve a family member, someone who is in the medical field. And I think that sometimes when people cannot think through a situation, it helps if there's a consensus among people that they know and trust. And that may even involve going outside of that doctor's office to get a second opinion. Would not

paul_roach:

I think

courtney_coke:

be an

paul_roach:

that's

courtney_coke:

unreasonable

paul_roach:

the magic

courtney_coke:

thing

paul_roach:

buzzword.

courtney_coke:

to do to, yeah, to get consensus and to get a sense of comfort with whatever you're being told. And I... I would think, you know, if you seek another medical opinion, you talk with your support system that's close to you and they're all kind of thinking it through, and you have the time to do that. I mean, I don't think you should feel pressed as if you should make a decision right there in the doctor's office, because this is a traumatic situation. You give yourself time to think it through. I think that may be a useful way to address the problem of feeling as if you're not being properly informed or guided through this process.

paul_roach:

I think that,

michael:

Is that kind of

paul_roach:

that,

michael:

a trigger? If I feel like

paul_roach:

yeah.

michael:

I'm not being informed, I should go get a second opinion.

paul_roach:

Yeah, I think that's the way to go. So the short answer, I think, is that the medical system as a whole is arranged in echelons, in tiers. And so you might have a, I work in a kind of a small hospital. And Peter, you work in a larger hospital, right? You're in a referral hospital? Then Courtney Uranus...

peter_schlegel:

Aye.

paul_roach:

Courtney's in a hospital that's sort of intermediate between my size hospital and a big tertiary referral center.

courtney_coke:

Yes, it's in the suburbs of Chicago. It serves a pretty large community. There are other hospitals around, but it's, you're right, I think it's an intermediate-sized hospital.

paul_roach:

And so if a person is thinking, you know, I just don't know, pardon me, I just don't know if I really am incurable or they just didn't give me any info. They just said I had cancer and then they left and you know, I think the agency they can... express is say, hey, can I get a second opinion? Not all situations are ones which are ideal for getting one if it's some kind of emergency and there's no time, but typically there is with this. And you say, can I get a second opinion? Typically you wanna go up a level. So if you're at a hospital that's my size, which is pretty small, you'd wanna get up to a larger one where there's more subspecialists. Wouldn't you guys agree?

courtney_coke:

Absolutely, Paul.

peter_schlegel:

Well, I think trust is the- the first issue that you have to have trust in your system and how can you get that? And as Courtney had said, you belong to a community and how can you use that community? And whether you know someone who's a cancer survivor and had an oncologist or radiation oncologist that they had, you had a minister that you can share this with, you have a neighbor who's a nurse, there generally is somewhere along the line you'll be able to find a connection of someone else who's had an established trust and kind of move forward. It is scary to be out there. And once you get diagnosed with cancer, you want the answer like right now. You want all these tests to be done. And it can be extremely frustrating that you have a scope and the doctor says you got a cancer and then we're gonna get you the latest and greatest PET scan, but then it's gonna be two weeks. And then until you can see the next list it's another week more and you're like I can't wait that long. It can be frustrating, but I think the important thing is to have a relationship. And I think one of the reasons why we're all sitting here is that we belong to a cancer community and we try to participate for our patients' well-being. And I think the vast majority of my colleagues of all different flavors who have an oncology title connected to them belong to a community who tries give patients the best outcomes tries to communicate but having said that it does fail and that is particularly early for a number of reasons.

paul_roach:

One other low tech option, I think Mike, is if you're gonna give that doctor one more chance, because everyone gets a bad day or whatever, is write down all your questions for the next visit. Write it down on a piece of paper, and when you show up, let the nurse know, say hey, I've got these questions I wanna answer. before I leave. And I have patients who

michael:

Okay.

paul_roach:

do that and that's been very, that's a very helpful way to make sure they get all their questions answered.

michael:

Well, it sounds like you guys are saying, because I know when I go to the doctor, which is, you know, I do my once a year checkup, and so I kind of know my primary care physician, and that's about it. And when I get referred to something, somebody else, a specialist for some reason or another, I don't know that person at all. And what you're basically saying is, okay, given that situation, don't be shy.

paul_roach:

Yeah, don't

michael:

Don't

paul_roach:

michael:

keep

paul_roach:

shy.

michael:

this to yourself. Reach out. Find people in your normal life, your family, your friends, the minister, anybody, somebody down the street, a neighbor, find somebody who is connected or who has been through it. And don't keep the sort of the cancer. buzzword, you know, it's a secret, right? You don't want anybody to know. And that's kind of a bad way to go. It's basically what you're saying. Get out there, let people know, get the help built up from your own network, your own community, so that you can kind of figure out the best way to get treatment for yourself, rather than rely on one statement from one professional. Yeah?

paul_roach:

Oh, without a doubt, that is perfect.

michael:

Okay.

paul_roach:

December,: 2021

michael:

A lot of big words for me, Paul.

paul_roach:

Alright, so here I'll talk to you about it. First of all, the trial is interesting. it's a multi-center trial. So it happens in New York, Japan, Chile, several places in China, Italy, Ukraine, Poland, Belgium, and Spain. And what they were looking at is these types of cancers that we're talking about, the adeno cancers, which happen at the base of the esophagus, and they also happen in the stomach. Classically, they would not been too well... treated by chemotherapy. It doesn't make that big a difference. Then they found a subset which has this receptor on it called the HER2 which is over expressed compared to a normal set of cells and you target that. And we were expecting really big drops in, you know, really big impact from this targeting because in breast cancer when the HER2 receptor is prominent and you target that, it works really well. It didn't work as well in gastric cancer probably because the HER2 isn't as dense densely or uniformly upregulated in the gastric cancer as it is in the breast cancer. thing this thing called the PD-1 antibody that's called pembrolizumab and and what it does is it it acts also with the HER2 the two of them together kind of like let's see shake and bake and teledoga nights, you know, the two together are a lot stronger and it actually made a pretty sizable impact

michael:

you

paul_roach:

and a big inroad in treating these gastric cancer patients. It didn't, you know, make everybody... Altogether better, but it was like a big breakthrough and so I think the reason I wanted to bring it forward was to say that these combinations of Medications and from different types the PD one is an immune type of modulator and the herd two is a receptor type of blockade The combination actually is new and impactful and exciting. And so when patients get these cancers, which just five years ago or 10 years ago were really, really hard to treat, right now there might be some trial just like this one that has a big impact and can really improve things beyond what has historically been the case.

michael:

Paul,

paul_roach:

What do you?

michael:

how bad does my cancer have to be to get into a trial like that?

paul_roach:

Oh, well there's experimental

michael:

Are they testing

paul_roach:

trials,

michael:

everybody?

paul_roach:

yeah.

michael:

So if I have it at all, right, I mean I can't necessarily get into it, but if I'm, who do they test? Do they test everybody from stage one to stage four? Do they mostly, like, is a trial like that for people who are in late stage?

paul_roach:

A lot of times the trials will begin with people who are in late stage and then the ones that show Real benefit and promise get moved earlier and earlier and earlier in the staging because if a person's got a stage one or maybe a stage two, you don't wanna change the mix too well because overall they typically have very good results. So you don't wanna mess with it too much unless you've got really good reason to. If a person's stage four, the results are oftentimes a lot harder to achieve and so you get a lot more experiment going on. But.

michael:

If I'm at any point

courtney_coke:

criterion.

michael:

I get a cancer diagnosis and you're talking about trials and you're talking about experimental tests, I get that, but what if I want to get into one? Is there a path for a patient to kind of explore that and try and work into that? Is that something I should be asking you guys at all if I'm a patient?

peter_schlegel:

Well, I think clinical trials offer a ton of benefit, both to the individual patient and to the science and arsenal for combating cancer. Typically, the clinical trials are often run at the university medical centers rather than in community, although... larger and larger segment of the private practices are running clinical trials. It is a small group of patients, unfortunately, that are eligible for those. Typically when you're seeking out a place to receive your cancer therapy, it's a good idea to research a potential center that does offer research opportunities. clinical trial in situations that are more dire, that we have less hopeful options, and basic, and if we do have good existing treatments, it's less encouraged and typically less available.

michael:

Well, Courtney, is that part of the plan that you were talking about that I should be asking about? Would you present that as an option in a plan or should I be pushing for that as part of my plan? What do you think?

courtney_coke:

I think it should be one of the questions that has to be checked off among those questions that Paul was talking about. Are there clinical trials available for my particular cancer, my particular stage of cancer? And this one that Paul is talking about has very strict criteria in terms of it has to have this, I mean, correct me if I'm wrong, Paul's her2 positivity to be ineligible for

paul_roach:

Right.

courtney_coke:

it, right?

paul_roach:

Yeah.

courtney_coke:

Yeah, so,

paul_roach:

Which is only 20%

courtney_coke:

yeah, so I think it's

paul_roach:

of the overall.

courtney_coke:

right. But yes,

michael:

What does

courtney_coke:

michael:

that

courtney_coke:

michael:

mean?

courtney_coke:

think

michael:

Sorry.

courtney_coke:

it... What did you say?

michael:

What does that mean? You guys were doctoring on me. Come on.

paul_roach:

Well,

courtney_coke:

Go for

michael:

You

paul_roach:

courtney_coke:

it, Paul.

michael:

dunking on me all day over here. Dunking on me.

paul_roach:

let's say there's a hundred people with edinocarcinoma of the esophagus. Hundred people.

michael:

Mm-hmm.

paul_roach:

Twenty of them will have a subset, will have a type of edinocarcinoma that has this HER2 receptor thing on it. Does that make sense?

michael:

Okay,

paul_roach:

and

michael:

well

paul_roach:

80%

michael:

how would we even

paul_roach:

won't.

michael:

know that? Are you guys testing for that?

paul_roach:

That's what we do. That's what you're paying us to figure out. Yeah. Yeah,

michael:

Okay,

paul_roach:

we're supposed to figure

michael:

so you'd

paul_roach:

that

michael:

come to

paul_roach:

out.

michael:

me and say you have this and you're in the 20% or you're in the 80%.

paul_roach:

Exactly.

michael:

If you're in the 20%, okay.

paul_roach:

Right. And then

michael:

then

paul_roach:

what

michael:

I can

paul_roach:

happens,

michael:

ask if there's a

paul_roach:

but

michael:

trial.

paul_roach:

what happens is worldwide is you've got people in China, Poland, Chile, worldwide. Everyone's trying to figure these same problems out. And everyone's trying to figure these same problems out. And so we're getting enough knowledge now that these things are so linked. These medical communities are linked across the globe. that we're able to get more and more of these subsets that we get tailored treatment for. So everybody's cancer might, you know, people might have different cancers than the esophageal cancer next door, but it might be very similar to the one that's in Taipei, Taiwan. And so you can, if you tapped into the, the most current treatment patterns for these kinds of things, you can find tailored treatments to your specific cancer type that might be better than otherwise. That's the benefit of

michael:

Okay.

paul_roach:

cancer centers and cancer subspecialists. Does that make sense? Instead of treating all 100

michael:

Yeah.

paul_roach:

of them the same, you say, aha! These squams get treated this way, the adenos get treated that way, then you look at the adenos and you break those into little categories. And you say, aha, the HER2 positive adenos should get treated this way, the HER2 negative should get treated that way. Then you take another look at the HER2 negatives and you look for other characteristics. Does that make sense?

michael:

Okay, but this is all where, yeah, but this is where you guys are doing that. And

paul_roach:

Right.

michael:

I may not even ever hear that as the patient, which then goes back to what Courtney was saying, is go out into the community, and Peter actually, go out into the community, talk to other people, find out what you can find out, because maybe another doctor had another patient who did talk about the same thing, and I can get the information that I need for my plan in a more, kind of in a more diffused way, I guess. So it's always good, I'm always bringing it back to basically your guys' core advice seems to be get out there and network so that you can find out about these things and find out if what you have is treatable in one of them or even just the regular treatment might it work for you. And just to branch out is basically

paul_roach:

Yeah,

michael:

what I'm hearing.

paul_roach:

I think any effort patients put into learning about the disease, talking to people who might be able to give them good information and support and looking into things and then communicating with their physician and nursing staff, I think is really well spent. I think that's a good effort.

michael:

But you guys have to promise me that you're not going to get annoyed with me for asking all my questions. You're

paul_roach:

No,

michael:

not going to

paul_roach:

that's

michael:

get annoyed

paul_roach:

why you're

michael:

with me.

paul_roach:

here.

michael:

I'm going to go, no, but there's a study. I heard there's a study. And you're going to go, oh, jeez, this guy with his study again. You've got to promise

paul_roach:

Yeah,

michael:

me. You're going

paul_roach:

Mike

michael:

to help

paul_roach:

found

michael:

me out.

paul_roach:

the

michael:

All

paul_roach:

internet.

michael:

right.

paul_roach:

Alright. Thanks again for listening and if you have a topic you would like to have us discuss or comments or feedback, please either log on to www.PaulBrienRoach.com, that's Brian with a Y, and click on the About and Contact page or send your questions directly to letters@PaulBryanRoach.com.

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