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Esophageal Cancer: Losing a Friend and Fighting Back

by Steven H. Lin, M.D., Ph.D.

Filed under | The State of The Fight

Esophageal Cancer: Losing a Friend and Fighting Back

I last wrote about esophageal cancer for SU2C’s blog in 2011. At the time, a friend and esophageal cancer patient was also invited to share his experience. Things were looking promising. He was about a year from completion of his “curative” treatment. He was working full time, thrilled to be able to see his three young children grow up. Yet he was also aware that, given the relatively low incidence of esophageal cancer, there was very little research funding specifically targeted for it. Thankful to be a survivor, he hoped to start a research foundation that would raise awareness and funding to accelerate cures.

Tragically, a few months later, my friend felt a nodule in his abdominal scar site. The site was biopsied and confirmed to be a recurrence. He underwent chemotherapy, but soon the disease progressed in his anastomatic site (the area where the surgery connected his upper esophagus and remnant stomach). Tests found the cancer seeding to the organs in his abdomen. Fluid began to accumulate in his lung and abdominal cavity. Not long after that, he succumbed to the disease, surrounded by friends and family in the ICU.

He was just 47 years old. As both a doctor and a friend, I was devastated.

I wish I could say my friend’s story was unique. But in 2013, nearly 17,900 patients will be diagnosed with esophageal cancer, and over 15,000 patients will die from the disease. Esophageal cancer is one of the western world’s fastest growing cancers. Thankfully, the rate for squamous cell carcinoma, a type of cancer related to alcohol and smoking, has begun to decrease in the US. Yet the rate of adenocarcinoma of the esophagus, a type of cancer that is associated with acid reflux and obesity, has increased in the past 20 years.

Technologies and techniques for radiation are becoming increasingly sophisticated, as are improvements in surgical techniques and postoperative care. Drugs to treat cancers are becoming more targeted, and chemotherapy continues to improve as we learn more about how cancers develop and grow. Advances in supportive care have also allowed patients to better tolerate the aggressive and often toxic treatments with and have a better quality of life.

These advancements have provided some improvements in increasing survival among esophageal cancer patients, mainly by reducing the toxicity of and deaths from cancer treatments. Where there has not been much improvement is in killing cancer cells. The cures rates for patients with esophageal cancer remain limited. We simply must do better.

One explanation why we are not substantially improving cancer cures is that we oftentimes deliver care in a “one-size-fits-all” approach. While we know some patients do very well with the current approaches, we are not very good at predicting who those patients are. Cancer is a genetic disease, so knowing the genetic “code” of the tumors and the patients would allow doctors to predict the side effects that certain treatments would have. There is still so much we don’t know about esophageal cancers, and cuts to federal funding for medical research and treatment reimbursement have made it increasingly difficult to provide innovative cancer care.

Certainly, philanthropic efforts like Stand Up To Cancer help bridge the gap to provide the much needed funding for innovative and impactful research. A personalized approach for cancer treatment is now being investigated for all cancers, including by three of SU2C’s Dream Teams. Team efforts through the formation of SU2C Dream Teams in multiple disease sites are already making a difference in diseases such as breast and prostate cancer. Ultimately, we hope these same efforts could also impact diseases such as esophageal cancer.

We also know that esophageal cancer is, to a large degree, a preventable disease. The majority of esophageal cancers arise from chronic irritation and damage of the esophageal lining, and are caused by dietary and environmental factors. Squamous cell carcinoma of the esophagus is strongly linked with tobacco and alcohol use, so stopping smoking and reducing alcohol consumption can help lower your risk. A diet high in green and yellow fruits, as well as cruciferous vegetables like cabbage, broccoli, and cauliflower, may also lower the risk of squamous cell carcinoma. Adenocarcinoma of the esophagus is strongly linked to gastroesophageal reflux disease (GERD), so if you experience trouble swallowing, weight loss, acid reflux and heartburn, be sure to speak with your physician.

In retrospect, my patient friend was at very high risk for the disease to return. The tumor did not respond very well to the standard chemoradiation that was given, as evidenced by the amount of viable tumor that was left at the time of the surgical resection. We know from experience that such patients are at very high risk for recurrence. However, without better chemotherapy, we had and have no choice but to observe all patients and hope that their diseases don’t come back.

So we are left with questions. Could a better understanding of the biology and genetics that underlie aggressive tumors lead to better treatment? Could knowing the molecular characteristics of my friend’s cancer have helped the physicians better treat it? Perhaps. But until this type of diagnostic test becomes a standard option, and the cost of such tests can be paid for, we will never know. Research needs to demonstrate unequivocally that such tests can make a difference in tailoring treatments and improving cures for patients.

There is an urgent need for future research to better understand why these tumors are not responsive to treatments, and identify better ways to kill these types of cancer without harming patients. We physicians and researchers who treat this disease know that with some creativity, resilience, and lot of patience, increasing the cure rate is not an impossible task. Our patients are counting on us to achieve it. If we don’t do it, who will?

Steven H. Lin, M.D., Ph.D., is assistant professor in the department of radiation oncology at The University of Texas MD Anderson Cancer Center in Houston, Texas. A radiation oncologist in the Thoracic Group, Lin specializes in thoracic malignancies including esophageal cancers. Lin is a collaborator with John Heymach, M.D., Ph.D., a principal on the SU2C Circulating Tumor Cell (CTC) Chip Dream Team.

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