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Step by Step to a Cure for Esophageal Cancer Patients

April 04, 2021

Dr. Stefan Kachala
Director of Thoracic Surgical Oncology
Hartford HealthCare Central Region

We are living in a new era of cancer care. Research seeks ways of preventing cancer, more targeted therapy for patients, and new minimally invasive surgical approaches.

These efforts serve our patients in bringing hope of a long healthy and happy life. In this article, I will discuss how we are bringing the cutting edge in oncologic care to our patients with esophageal cancer.

Esophageal cancer is a rare entity affecting 1 percent of patients with cancer in the United States. But its impact can be devastating: Nearly 20,000 new cases are expected this year and over 15,000 people will lose their life.

In Connecticut, our incidence of esophageal cancer is slightly higher, but patients have access to a range of specialists. The focus of care in esophageal cancer can be divided into four phases:

  • Prevention.
  • Precancerous treatment.
  • Excisional surgery.
  • Systemic therapy.
  • Palliation.

The Hartford HealthCare Cancer Institute, seeking to provide the best care for our patients, has developed a center of excellence in esophageal diseases to ensure the best care coordinated by the patient’s physicians.

These disciplines include:

  • Primary care.
  • Gastroenterology.
  • Thoracic surgery.
  • Radiation oncology.
  • Medical oncology.

Preventing esophageal cancer is of paramount importance. Higher rates of esophageal cancer are seen in patients who smoke, consume more alcohol and are overweight. Our primary care providers promote smoking cessation, moderation or elimination of alcohol consumption and recommend regimens to a healthy active lifestyle. These measures make an incredible impact in reducing the chances in developing esophageal cancer. Another common culprit in esophageal cancer is reflux disease.

Acid refluxing into the distal esophagus induces a change in the growth of cells that develops Barrett’s esophagus. The medical term is called metaplasia, as the acid causes the esophageal cells to make mucus to protect themselves from the acid as stomach cells do.

But the transformation causes other changes in the cells, leading to more and more disordered, uncontrolled growth – cancer. This timeline is not set in stone, and can range from months to years. Happily, research has demonstrated that this process can be stopped and even reversed with treatment of the reflux and Barrett’s.

These patients require close follow-up and surveillance with endoscopy. Endoscopy facilitates biopsies which look for dysplasia or disordered growth of cells. These are considered precancerous. Current research is examining the role of NSAIDs (nonsteroidal anti-inflammatory drugs) in preventing the progression to cancer.

Radiofrequency ablation, an approved therapy for Barrett’s esophagus, is endoscopic with no incisions and same-day surgery. The ablation burns the surface of the esophagus, destroying the barrett’s esophagus. As the esophagus heals, the normal lining regrows. Surveillance is critically important to identify those patients with early cancers or prevent the development of cancer. Early stage patients have the best chance of cure, but typically they don’t have any symptoms. These biopsies help identify those early stage patients.

Excisional therapy can be performed by a gastroenterologist endoscopically or by a thoracic surgeon. Once an endoscopic biopsy reveals esophageal cancer, the next step involves imaging (CT and PET scans) as well as endoscopic ultrasound. The ultrasound allows the measurement of the size as well as the depth of invasion in millimeters.

Shallow lesions can be surgically removed endoscopically. This is an incredible advance in the care of esophageal cancer. Previously, all patients needed an esophagectomy. Today, small shallow (1-2 millimeters deep) esophageal cancers can be removed without any skin incisions and go home the same day! After the endoscopic excision, the pathologist will examine the biopsy specimen. If there is evidence of microscopic cancer cells near the margin of the resection, the patient will need additional therapy.

For patients strong enough to undergo surgical resection, the standard of care is an esophagectomy.  Early stage patients will not need chemotherapy or radiation before surgery. Today, our group of thoracic surgeons at Hartford HealthCare employ minimally invasive techniques as well as robotic surgery. This results in less pain, more mobility, and a faster recovery.

Less pain allows us to help mobilize the patient – get them up and walking the day after surgery. This is crucial in helping increase the pace of the patient’s recovery. Previously, painful large thoracotomy (chest) and laparotomy (abdomen) incisions led to a long and arduous recovery. Now, with robotic surgery, most incisions are less than 1 inch.

Chemotherapy and radiation are employed in larger tumors to help shrink the lesion or with curative intent in patients who cannot tolerate surgery. Using evidence-based approaches to treatment, we can cure patients of esophageal cancer with chemotherapy, radiation and surgery. Depending on the biology, some oral chemotherapy drugs can be used.

Current research is aimed at exploring immunotherapy in esophageal cancer as well as new antibody therapies. Ultimately, the goal is a cure that restores the quality of life patients experienced before their diagnosis.

Esophageal cancer was once associated with a poor prognosis. Today, with our evidence-based approaches, we make sure our patients have hope for a cure. Our tools in prevention — minimally invasive surgery and cutting-edge chemotherapy and radiation — are all part of the team-based approach to patient care.

Working together, my colleagues and I treat the whole patient: mind, body and soul.

Dr. Stefan Kachala is Director of Thoracic Surgical Oncology for Hartford HealthCare’s Central Region.