Stomach and Esophageal Cancer Q&A

While cancers of the stomach and esophagus are rare, these cancers are usually advanced by the time they are detected. An expert medical oncologist sheds light on diagnosis, risk factors and treatment.

How are stomach and esophageal cancers diagnosed?

Patients diagnosed with esophageal cancer often start with concerns about difficulty or pain during swallowing, weight loss or a cough and hoarseness. Those diagnosed with stomach cancer often first notice a general discomfort in the stomach, loss of appetite, weight loss and vomiting. Screening generally includes an upper endoscopy, a procedure in which a thin scope with a light and camera is used to look inside the upper digestive tract.

Why do stomach and esophageal cancers occur?

Smoking, heavy alcohol consumption, and diets rich in fats and salt and lacking in fresh fruits and vegetables can lead to these cancers. Increasing age, gender (men are more likely to develop these cancers than women), obesity and lack of physical activity are also potential culprits.

Once diagnosed with stomach and esophageal cancer what are the treatment options?

Multimodality treatment (surgery, radiation and chemotherapy) is often used. Sequencing of treatment is determined by the stage, size and location of the tumor.

What types of surgeries are performed for stomach and esophageal cancer?

A process known as “endoscopic mucosal resection” removes the cancerous area through an endoscope. Subtotal gastrectomy, removal of part of the stomach, is used for cancer located in the upper part of the stomach. If the cancer has spread throughout the stomach, a total gastrectomy will remove the stomach and rework the digestive tract. For esophageal cancer, surgery may remove some or most of the esophagus through an esophagectomy.

How are radiation therapies used?

  1. Prior to surgery if the cancer is localized to the esophagus. Studies show the survival rate is improved when chemotherapy and radiation therapy are given together before surgery
  2. With stomach cancer and occasionally esophageal cancer, if patients undergo surgery without getting radiation or chemotherapy prior to surgery, it is sometimes advisable to give chemotherapy and radiation therapy after surgery to help clean up the cells that may have been left behind at the time of surgery.
  3. Radiation therapy can sometimes be used to control pain or bleeding from cancer. In this case a short course of radiation therapy is given, usually without chemotherapy, for local control of a tumor that is causing pain or bleeding even if patients have metastatic disease.

What is the best chemotherapy regimen for stomach and esophageal cancer?

Chemotherapy treatment options usually include between one and three drug combinations. The three-drug combination tends to induce the highest responses but also has the highest rates of side effects.

Why do some people have radiation therapy and chemotherapy while others just have chemotherapy?

Radiation therapy is used when cancer is localized to one area like the esophagus or stomach.  When cancer spreads outside the local area to the liver or lungs it usually spreads through the blood.  When this occurs, the cancer is no longer localized and other treatments are needed. 

What are the benefits of adding chemotherapy to radiation therapy?

Adding chemotherapy to radiation therapy augments the effects of radiation therapy. Chemotherapy also helps control cancer cells that might be trying to escape into the blood.  When given alone or in combination with radiation therapy, chemotherapy may help alleviate symptoms related to stomach cancer. In patients with more advanced stomach cancer in whom surgery is not possible, chemotherapy may also improve both the length and quality of life.

GI Cancer: The Promise of Targeted Therapies

Targeted therapy offers a new hope for cancer patients and opens the door for the development of new treatment strategies for patients who carry certain genetic mutations in their tumors.

One condition treated effectively with targeted therapies is gastrointestinal stromal tumors (GIST), the most common type of sarcoma which occurs when abnormal cells grow in the gastrointestinal track. With July recognized as Sarcoma Awareness Month and July 13th as GIST Awareness Day, it’s the ideal time to draw attention to the growing body of evidence suggesting that GIST tumors—which don’t respond well to chemotherapy or radiation—can be treated effectively with targeted therapies such as tyrosine kinase inhibitors (TKIs).

All cells in the body are regulated by DNA that controls cell growth. Cancer cells typically have DNA mutations—changes in the normal DNA—that can cause rapid and unregulated growth of the cancer cells, leading tumors to grow and spread to various organs.

Specific mutations have been identified as main drivers for growth in GIST tumors. Targeted therapies combat these mutations by blocking the molecules that allow tumors to grow. TKIs can treat the tumors effectively or shrink them enough that surgery becomes an option. This approach precisely targets mutations that are predominantly present in cancer cells and offers a new way to control cancer cells without significantly affecting normal cells.

Our physicians at the Zangmeister Cancer Center strive to provide patients who have certain genetic mutations with access to clinical trials that include new targeted therapies. This is done by gathering information on the patient’s personal and family history of cancer. We then biopsy the tumor and send the tissue sample to a lab for genetic analysis. The results are then carefully reviewed to determine if targeted therapy—some of which are FDA approved while others are part of clinical trials—may be effective. This is an alternative to the more conventional “one-size-fits-all” approach to treatment and helps sidestep the cost and side effects associated with treatments that may not work on certain mutations.

This approach continues to evolve, and most likely will help increase the number of targetable mutations and available targeted therapies available to patients over the next years. This is an exciting time to be treating cancer, implementing new therapies that will lead to even more new tools for success.

Breast Cancer in Men: Recognizing Symptoms, Reducing Risk

Breast cancer is most often associated with women, which is understandable as more than 276,000 women are expected to be diagnosed in 2020. Yet, breast cancer occurs in 1 of every 83 men and carries a 5% mortality rate.

Consequently, men need to be vigilant and educated about the symptoms and signs of breast cancer and should feel comfortable discussing them with their physician.

Symptoms of Male Breast Cancer

The clinical features of breast cancer in men are no different than they are in women. Symptoms include a lump or thickening in or near the breast or underneath an arm. A dimpling or puckering of the skin—known as peau d’orange—can also be a symptom, particularly of inflammatory breast cancer, and the nipple of the breast may be inverted. Another thing to look for is nipple secretion, which can be especially concerning if the drainage is blood.

No one is immune to cancer, but there are some factors that can heighten the risk of breast cancer in men, including exposure to radiation and a history of breast cancer in their family. An increase in a man’s estrogen level can also heighten the chances of breast cancer, so conditions such as Klinefelter’s syndrome and cirrhosis are risk factors. Transgender men using estrogen injections are also at an increased risk.

Self-Examination and Treatment

Like women, men should do routine self-examinations and check for thickening or lumps in the breasts. The best screening is a simple palpating of the tissue and checking in a mirror for any changes in the look of the breast’s skin or nipple. This should be done once a month, especially for men with a family history of cancer.

If any irregularities are noticed, reach out to a physician immediately. In the event of a tumor, the procedure for men is the same as women – a biopsy followed by a diagnosis, and then the decision whether to do surgery with or without chemotherapy or radiation therapy.

One of the biggest differences regarding breast cancer treatment in men and women is endocrine therapy. Aromatase inhibitors, which stop estrogen production in postmenopausal women, are used to treat women whereas men are typically treated with tamoxifen, which blocks the effects of estrogen in breast tissue. The reason for the difference is the insufficient amount of data supporting use of aromatase inhibitors to treat male breast cancer.

Erasing the Stigma

Cancer takes an emotional and mental toll on anyone it strikes. But because breast cancer is so strongly associated with women, men often face additional psychological challenges.

Some may feel their manhood is in question once they hear the diagnosis or they may become embarrassed by it. While stigmas are real and can be debilitating, the reality is that male and female breasts are made of the same tissue.

Consequently, psychological care is a big component of treating breast cancer in men, especially for patients with estrogen-receptor-positive cancer—the most common form of breast cancer wherein estrogen receptors on the surface of the cell bind to estrogen and enable the cancer to grow. In men, this means they are creating more estrogen than progesterone, which can make them feel like less of a man. Therefore, taking extra time to address stigma is an extremely important element of care.

Scarring is another concern. Reconstructive plastic surgery isn’t offered for men who undergo surgery to treat breast cancer, so it is important to remind male patients that the scar does not make them less of a person. In fact, the scar should be looked at as a symbol of the surgery that may have saved their life.

Resources for Men

In tandem with the multitude of female-driven support systems in place for women, such as the saturation of pink every October to mark Breast Cancer Awareness Month, there are also good resources for men battling breast cancer.

The Male Breast Cancer Coalition and the Young Survival Coalition are helpful resources offering information about male breast cancer, as well as hotlines and support groups.

It is important to remember that cancer can happen to anyone – and while breast cancer in men is rare, it is real and can be deadly. As providers and oncologists, it is important that we recognize the physical and mental components of working with male breast cancer patients and provide the support systems that deliver optimal care outcomes.

Oncology Care First: The Wave of the Future

With COVID-19 on the forefront of everyone’s mind, it is difficult to remember that the decade started out with an uplifting headline in cancer care: the largest single year drop in cancer mortality.  We also saw emergence of the next generation oncology model, Oncology Care First (OCF), which comes on the heels of a successful first-of-its-kind model, the Oncology Care Model (OCM).

As you shuffle through the countless articles, studies, and theories, there are many factors that play into the reduction in cancer deaths, many associated with science, demographics, society, and a change in the delivery of healthcare. Regardless of why, the news is a welcome development at a time when the nation is in the midst of a pandemic that continues governing our lives.

I am fortunate to be a frontline witness to one of the best stories in cancer care to hit our inboxes, thanks to my role within American Oncology Network (AON), one of the fastest growing oncology networks in the nation. I am charged with protecting community oncology by securing funding through revenue cycle processes. However—and more importantly—my role challenges me to think about how cancer care is constantly changing in our drive for better outcomes, enhanced delivery methods, lower costs, and a focus on value, which in turn requires that we challenge the “norm” of reimbursement methodologies.

A Quest for Innovation

Since its inception in 2018, AON has helped lead the charge to create new methodologies through key payer partnerships such as with the Center for Medicare & Medicaid Innovation (CMS Innovation Center) and its Oncology Care Model (OCM). This commitment to change has helped drive AON’s growth. For example, its involvement with OCM was an important factor behind the decision by Genesis Cancer Center—which has been part of OCM since the initiative began in 2016—to partner with our network.

Born out of a group of seasoned oncology professionals seeking to create a first-of-its-kind oncology focused value-based model, AON ensures that its practices have a seat at the table to participate in models with the potential to transform cancer care. This includes the OCM, which permitted oncology providers to improve health outcomes for cancer patients through specific reimbursement methodologies that reward value over volume. And, as its network proliferates, the AON philosophy provides its oncology partners with the flexibility to change with emerging methodologies such as Oncology Care First (OCF), introduced by CMS Innovation Center in late 2019.

As AON develops an oncology network that, while geographically diverse, is interconnected through a rapidly growing dichotomy of oncologists and a cancer team focused on building an infrastructure to support declining cancer rates, partnerships and advanced reimbursement methodologies like the OCF are key. Payment models are complex, and the most critical part of these models permits the autonomous delivery of cancer treatments and support services—something AON continuously promotes among our local care teams.

Benefitting Physicians, Patients and Outcomes?

So now the question is whether there is a correlation between the adoption of a first-of-its-kind oncology focused payment reform model and the historic decline in cancer mortality rates. Within this next payment model, it is proposed that physicians who participate in OCF will still have the freedom to manage patient care and run their practices as they see fit. However, with OCF, they have better access to a pool of data from OCM that can guide clinical and administrative decisions and connect any dots between the model and outcome trends.

With this next generation of reimbursement, AON’s focus is on infrastructure development to support the balance between the various elements that consumers expect: value, outcomes, accuracy and timeliness. All of which is more important than ever. The network’s model is positioned to support this shift in attention as we can deliver the administrative expertise, infrastructure, and economies of scale necessary to optimize the transition to value-based care initiatives like OCF.

Wave of the Future?

OCF has great potential to be a win for independent practices, their physicians and, most importantly, their patients. This is particularly true for those that partner with networks like AON. Doing so not only streamlines participation in initiatives like OCF with access to administrative expertise and the technology required for data collection requirements, but it also helps optimize involvement by offering turnkey access to newly covered benefits like extended care services in areas such as nutrition, anxiety and depression.

Most importantly, it is a partnership that puts them on solid footing for the future by reducing costs and improving quality of care—without sacrificing their clinical autonomy.

The Benefits of Community-Based Clinical Trials

May is National Cancer Research Awareness Month and the ideal time to explore the crucial role clinical trials play in the field of oncology. Thanks to ongoing research and discovery, the industry has witnessed a host of medical breakthroughs, including development of new medications and therapies that can advance cancer treatments and help better the lives of cancer patients.

Community-based research offers a notable advantage to smaller, independent practices primarily due to one factor: patients do not have to travel far to participate in a clinical trial, which can boost enrollment and advance scientific knowledge.

While this helps practices overcome one of the greatest hurdles to getting clinical trials off the ground, they must still be well-prepared and properly equipped before moving forward—and most will benefit from a partner capable of streamlining their efforts.  

Trial Prep

Conducting clinical trials, whether in a lab or a small practice, is not for the faint of heart. First, physician groups need to catch the eye of clinical trial sponsors, who tend to gravitate toward larger practices with more expansive patient pools. The best way to do this is through a proven track record, which of course requires successful completion of at least one study.

Training and education are also required. Physicians and research professionals interested in running a clinical trial must undergo mandated training through the FDA’s Office of Good Clinical Practice (OGCP), which must be updated on a regular basis. And though not required, it is important that clinic staff on both the administration and clinical sides of the house be educated on the nuances of conducting a trial. This will help ensure compliance with required protocols.

Also, while many clinical trials have similar administrative requirements, oncology-focused research is unique because patients are facing a life-threatening illness. Not only is it more difficult to identify the right pool of potential participants, it also requires the right tools and extra time to ensure they are fully informed and able to make educated decisions about their involvement.

Through consent forms and in-person meetings, physicians need to work one-on-one with the patients to outline clinical protocols, risks, and benefits of the trial. It’s important for patients to understand that they are under no obligation to take part in any clinical trial and can withdraw at any time and for any reason. This is true for any trial – but because oncology trials involve severe and life-threatening illness, it is especially important to be candid and thorough with cancer patients.

Practices should also be prepared to dedicate additional resources for the increased administrative tasks, particularly patient-related documentation and record-keeping that accompany clinical trials.

Streamlined Partnership

Partnering with a network such as the American Oncology Network (AON) can streamline the clinical trial process, making it possible for independent practices to play a role in advancing cancer therapies. We not only support the heavy lifting on the administrative side, but also supply expertise and technology to help practices host more complex and, ultimately, more successful trials. For example, we bring to the table the equipment necessary to assist with blood and tissue sampling and testing, which allows practices to carry out certain trials that would otherwise be out of reach.

One of our most unique assets to a practice, however, is the ability to take a patient’s molecular characteristics and match them with a specific clinical trial. We use technology to help us identify those patients that match a study’s criteria and would potentially benefit most from participating. For example, use of EHRs and other systems enables us to match patients with trials based on criteria such as molecular defects or a change in tumor type.

Through AON’s streamlining efforts, we can help practices conduct their own trials, regardless of size, and help build their research programs. When it comes to community trials, working with AON provides access to over 35 years of expertise to assist in this area.

We also offer a high level of flexibility that lets us support practices engaged with clinical trials when the unexpected happens, like the current pandemic. COVID-19 has put a temporary hold on enrollment for some trials because of an inability to supply certain drugs, while others have paused their trials because patients aren’t able to travel or come in for regular lab work and other assessments required in all trials.

At AON, however, many of our trials are still up and running because they can operate remotely. Physicians and clinical trial coordinators within practices can securely access patient records and meet with trial participants via telehealth. Through the pandemic, we have worked closely with our research partners to make sure they can continue all required monitoring of our research through secure remote access.

The Case for Community

Community-based clinical trials come with many benefits for independent practices. They enable patients to be matched with potentially life-saving research while staying within the comfort and familiarity of their oncologist’s office. Because this can accelerate enrollment, community-based trials often yield faster results—helping to move the science forward.

But running clinical trials can be an arduous and resource-intensive process. A network like AON, with its technology and decades of experience, can help streamline the process, putting clinical trial work within reach of even the smallest practices.

Addressing Oncology Care Continuity During a Public Health Crisis

Crisis situations often call for creative solutions in healthcare and lean on the true strength of provider-patient relationships. While the stress of the COVID-19 pandemic is experienced across all walks of life, those with chronic or life-altering illnesses face unique challenges.

Care delivery for these patients cannot be put on hold. When dealing with a health crisis of such monumental proportions, oncology practices must identify ways of keeping patients safe and on track to achieve optimal outcomes. For cancer patients, the best approach ensures the full spectrum of care is addressed, including treatment, nutritional and emotional support.

Rolling with the Changes

Amid stay-at-home and social distancing orders, oncology practices remain essential and cannot simply shut their doors. Instead, providers need to adapt the way they run their practice while still maintaining continuity of care.

Our providers at American Oncology Network (AON) have deferred non-critical visits, such as six-month and annual follow-ups, but are continuing to see patients who are undergoing treatment or are newly diagnosed. In addition, we check with patients prior to each visit to determine if they are experiencing any symptoms associated with the virus – such as fever, cough, shortness of breath – and require they wear a mask to their appointment. One AON practice in Columbus, Ohio, screens patients for symptoms in a tent outside their facility before allowing them inside. All staff members have their temperatures taken daily, before and after each shift, and non-essential visitors are required to wait outside the clinic.

Amid industry shortages, our procurement team has done a tremendous job of ensuring our practices have the supplies they need to keep their facilities clean to ensure the safety of our patients – even going “old school” to overcome the lack of pre-packaged disinfectant wipes by utilizing paper towels and  FDA approved cleaning solvents.

The Rise of Telehealth

Telehealth, which allows patients and physicians to communicate through videoconferencing, is experiencing a significant surge in utilization – not only because the COVID-19 pandemic has made it a necessity to conduct patient appointments remotely, but also because the Centers for Medicare and Medicaid Services has relaxed reimbursement requirements, with many commercial plans following suit. Telehealth is expected to remain popular even after the pandemic is gone.

Our physicians understand the benefits of developing personal relationships with each of their patients, which typically begin with a face-to-face visit. Over time, however, as the bond between doctor and patient grows stronger, telehealth may become a very viable alternative where appropriate. This current health crisis has simply accelerated its acceptance and adoption. And while there are some long-term issues to figure out, the COVID-19 pandemic has taught us that telehealth is essential to maintaining patient access to high-quality care.

Unfortunately, as could be expected, many small, independent community practices lack the IT expertise, bandwidth or technology to implement telehealth quickly enough to effectively serve their patients. Thankfully, because of the existing infrastructure and technical expertise at AON our growing network of more than 130 providers was able to offer virtual appointments via telehealth to their patients within a span of four days and all locations are conducting these types of appointments daily.

Compassionate and Patient-centric

While telehealth has become an essential part of practicing medicine, our practices haven’t lost sight of the emotional needs and mental health of our patients. AON addresses this through triage nurses and social workers proactively reaching out to patients suffering from depression or struggling with the isolation that comes with the current social distancing measures.

I cannot stress enough, especially under these circumstances, the importance of why we are in this business – to provide our patients with the best care possible.

Our patients are at the center of everything we do and every decision we make. Now, they need us more than ever. We are taking every possible step to continue providing exceptional care, safely and compassionately.