Comprehensive, relevant and insightful conversations about health and medicine from the largest healthcare system in the Maryland D.C. region: this is MedStar Health DocTalk.
In our latest podcast episode, host Debra Schindler talks with thoracic surgeon Dr. Duane Monteith and gastroenterologist Dr. Dana Sloan for a comprehensive look into esophageal cancer. They discuss everything from early symptoms and risk factors to advanced treatment options like minimally invasive surgery. This episode is packed with valuable insights that could make a significant difference in early detection and treatment.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
Comprehensive, relevant and insightful conversations about health and medicine from the largest healthcare system in the Maryland D.C. region: this is MedStar Health DocTalk.
In our latest podcast episode, host Debra Schindler talks with thoracic surgeon Dr. Duane Monteith and gastroenterologist Dr. Dana Sloan for a comprehensive look into esophageal cancer. They discuss everything from early symptoms and risk factors to advanced treatment options like minimally invasive surgery. This episode is packed with valuable insights that could make a significant difference in early detection and treatment.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
Comprehensive, relevant and insightful conversations about health and medicine happen here on MedStar Health Doctor, you're listening to MedStar Health DocTalk Real conversations with physician experts from around the largest healthcare system in the Maryland DC region. Consider the human esophagus. It's a unique motility agent, a hollow tube for which food travels from the throat to the stomach. Though rare compared to other cancers, when cancer cells form in the lining of the esophagus, they tend to grow aggressively, making it the 6th deadliest cancer in the world. On average, four people out of every 100,000 in the US will get an esophageal cancer diagnosis. 25% of them won't know they have it until it's in a late stage. Detecting esophageal cancer early is key, and here at MedStar Health, we want to be sure that you recognize possible early symptoms. Who is at risk? What diagnostic tests and treatment options are available? I'm happy to welcome thoracic surgeon doctor Duane Monteith and gastroenterologist doctor Dana Sloane to learn all we can about esophageal cancer. I'm your host, Debra Schindler. Doctor Monteith and Doctor Sloan, I'm so glad to have you both back. Thank you for being here on DocTalk
>> Doctor Duane Monteith:Thank you.
>> Doctor Dana Sloan:Thank you for having us.
>> Debra Schindler:So, thoracic surgery, I get the esophagus is in the thoracic section of the body, which as we know, is at the neck to the diaphragm.
>> Doctor Duane Monteith:Yes.
>> Doctor Dana Sloan:Okay.
>> Debra Schindler:But gastroenterology, where does that fit with esophageal health?
>> Doctor Dana Sloan:I would say in general, gastroenterologists, are on the diagnostic end of things in terms of accepting patients who may present with symptoms consistent, with either Gerd or esophagitis or more concerning symptoms that could be related to cancer. we will tend to do the diagnostic testing that may reveal an esophageal cancer diagnosis and then from there doctor Monteith's team would take over more, you know, in depth discussions about treatment.
>> Debra Schindler:And there's two kinds.
>> Doctor Duane Monteith:So, esophageal cancer is a cancer of the esophagus. the two main types and by far the most common types are going to be, squamous cell carcinoma and adenocarcinoma. So squamous cell carcinoma is the, a, cancer of the thin cells that form the inner lining of the esophagus. those are more commonly seen in the upper two thirds of the esophagus. And then there's, adenocarcinoma, which is the cancer of the glands of the esophagus, which is usually seen in the lower third. But over time, things have changed and we're seeing both cancers in all parts of the esophagus.
>> Debra Schindler:Is one worse than the other, would you say? Is one harder to treat than the other?
>> Doctor Duane Monteith:Not necessarily. The treatment is going to be based on location of the cancer, or the difficulty of treatment is going to be based on the location of the cancer. In what portion of the esophagus. The higher up, typically the more difficult to treat. The treatments are generally the same, but there are subtle differences in terms of how squamous cell carcinoma is treated compared to adenocarcinoma. But again, the mainstays of treatment are going to be chemotherapy, radiation and surgery, in that order, or in some combination.
>> Debra Schindler:How are the symptoms different?
>> Doctor Duane Monteith:So the symptoms are going to be based on the location of the tumor. So higher up tumors are going to be more like symptoms of gagging, difficulty swallowing, not being able to get food down, hoarseness. And at the lower part, it's going to be more so later, regurgitation, meaning you ate, and then about an hour later, you're just bringing back, back the food up.
>> Debra Schindler:You mentioned hoarseness, so that makes me think esophageal cancers at the top would be the throat.
>> Doctor Dana Sloan:Throat or oropharyngeal cancer is going to be different than cancer in the upper esophagus, but they can have overlapping symptoms, including hoarseness, coughing, throat irritation. But remember, for a patient to truly localize, where a problem might be in their esophagus, it's a little difficult using symptoms alone. But doctor Monteith is correct. Cancers higher up on the esophagus can have those features of hoarseness.
>> Debra Schindler:Okay, so the symptoms lower in the esophagus, what would they be more?
>> Doctor Duane Monteith:So, regurgitation, meaning you eat a meal and sum up a meal, and, you know, several minutes to an hour later, you're bringing that back up versus just, you know, as soon as you eat, you're bringing it up, because the esophagus has the ability to expand and actually hold a significant amount of food, before you have that urge to bring it back up. But I think the more common symptoms that we see, other than the difficulties following or the regurgitation, the vomiting, it's going to be the standard cancer symptoms, like unexpected weight loss, loss of appetite, those kinds of things.
>> Debra Schindler:And, what stage do people start becoming symptomatic?
>> Doctor Duane Monteith:It could be at an early stage, or it could be at a very late stage. unfortunately, with esophageal cancer, because the esophagus is kind of tucked away in the middle of the body, the symptoms are going to present a lot later. At a later stage.
>> Debra Schindler:What are the diagnostics then? what's the first step in trying to get a diagnosis on esophageal cancer?
>> Doctor Dana Sloan:Generally, when a patient comes in to see us and they, they're having dysphagia or just difficulty swallowing, they're having weight loss, they're newly anemic without an explanation. Endoscopy is really one of the first tests that we'll offer to evaluate that. doctor Monteith is correct. By the time a patient has dysphagia or food is getting stuck, generally it's a progressive dysphagia. In patients who have esophageal cancer, first they have trouble with meats, and then they have trouble with softer foods and they have trouble with liquids. You can see this progression of the steps of dysphagia, but we'll bring those patients in for an endoscopy, procedure wherein, under sedation, a camera is placed in the mouth and down into the esophagus as a part of that test. We're also examining the stomach and the part of the small bowel as a standard part of the test. But, for patients with these esophageal symptoms, we obviously spend a great deal of time looking at the esophageal lining very carefully.
>> Debra Schindler:And why is there a difficulty for swallowing or why do those symptoms occur? Is that because there's tumors in the way?
>> Doctor Dana Sloan:Yeah. Mechanical blockage is going to be the most common cause of dysphagia. But, you know, keep in mind, not all dysphagia, not all difficulty swallowing means that you have esophageal cancer. There can be esophagitis, there can be motility problems of the esophagus, thinking of it as one great big long muscle. There can be, you know, strictures or narrowing of the esophagus. It's not a cancer. So, you know, we'll offer endoscopy as kind of a starting diagnostic test to see if we can sort out what's the underlying cause of someone's and swallowing difficulty.
>> Debra Schindler:So you're getting a visual at that point.
>> Doctor Dana Sloan:Exactly.
>> Debra Schindler:But to distinguish it from, what did you call it? Esophagitis.
>> Doctor Dana Sloan:So esophagitis is inflammation of the esophagus. again, there can be motility problems that you might not pick up on an endoscopy, but you'd see basically the absence of anything structural. Or there can be strictures, which are narrowing of the esophagus, and some of those can be malignant or cancerous. Many are not, and they're just related to, most commonly, acid injury over time.
>> Debra Schindler:What would be the next step then? A biopsy?
>> Doctor Dana Sloan:Yes. So if we see a mass lesion in either the upper esophagus or the lower esophagus, we get biopsies at the time of endoscopy. those don't hurt. I get asked that question quite a bit. You don't feel when a biopsy is being taken, generally speaking, an experienced gastroenterologist is going to be able to tell you if they are strongly suspicious for esophageal cancer at the time of endoscopy. But we do wait on the biopsy results to confirm that diagnosis or exclude it from there.
>> Debra Schindler:How long does that take?
>> Doctor Dana Sloan:The biopsies, the procedure itself, ten minutes. That's a very short procedure. But in terms of waiting to get the biopsy results back within days.
>> Debra Schindler:Okay, so it's not like you're standing in the operating room or the procedure room and you're getting something back from pathophysiology.
>> Doctor Dana Sloan:Not for our procedure. You'll hear differently from doctor Monteith, some of his surgical evaluation, but, in terms of during the procedure? No, we get, those path results back, usually a few days later.
>> Debra Schindler:Do you have to test the lymph nodes then?
>> Doctor Dana Sloan:So we don't do that at the time of procedure. We're proceduralist, we're not surgeons, so we're just looking at, in the esophagus. I will say that there is a staging procedure that we can do that's also endoscopic, something called an endoscopic ultrasound, or EUI, that is a staging procedure. So once a person has been diagnosed with a mass lesion in their esophagus, that's a staging procedure to help us determine how deep into the wall is this mass growing, and are there lymph nodes in the area that are of concern. So our interventional gastroenterologist can then do a follow up procedure after a diagnosis of esophageal cancer is confirmed to assess the depth of the mass lesion and then, if appropriate, sample the lymph nodes in that area at the time. We can also take a look at nearby structures, including the liver, to see if there's any evidence of regional metastasis or spread of the cancer.
>> Debra Schindler:Okay. A patient comes in, they have these symptoms. You do an endoscopy, you send off something to pathology that you've extracted during a biopsy procedure, same time, then you get the results back. What would be the next step?
>> Doctor Dana Sloan:So we would then talk to the patient about getting some initial staging procedures done. That would include the endoscopic ultrasound, like we just talked about. will also probably include imaging. So, generally we're starting with CAT scans just as an initial step. CAT scans of the chest, the abdomen, the pelvis. Again, look for any spread of the disease. right away. We're also getting that patient referred to thoracic surgery and oncology when appropriate.
>> Debra Schindler:Well, there aren't any routine screenings for esophageal cancers, like there are mammograms or colonoscopy, for example, but there are tests. And who would qualify for that? Because I've read about esogard.
>> Doctor Dana Sloan:Esogard, yeah, DNA test, also, that has.
>> Debra Schindler:You look a little iffy about that.
>> Doctor Dana Sloan:Well, it's commercially available in the US. It currently has an FDA breakthrough designation. It's not something that is in widespread use. so if I have a skeptical look, it's just because I never use it for any patient. So, will, it achieve primetime status, one day, as a viable screening option for patients to avert the need for endoscopy? It's possible. It's, kind of in the vein of cologuard. It's a DNA based test to basically sampling cells in the lower esophagus to check for DNA markers that could indicate esophageal cancer or precancerous lesions. But again, it's not in wide clinical use.
>> Debra Schindler:Okay, so it's not actually diagnosing cancer, identifying something else that would lead to cancer.
>> Doctor Dana Sloan:It could do either identify cancer or a precursor to cancer, but again, not in widespread use.
>> Doctor Duane Monteith:And then the other, modality is what's called, blood tests, or termed liquid biopsies, which are. There's, several tests that are in trials now that they draw a vial of blood and they check the blood for tumor DNA, circulating tumor DNA. There's nothing that is DA approved at this point. Detection of esophageal cancer from, you know, from a liquid biopsy. However, I think they're making a lot of important gains in terms of the accuracy of these tests.
>> Debra Schindler:Okay, so I have a note here that they're screening key points. Now, maybe this is just part of the biopsy. A brush cytology, balloon cytology, chromo, endoscopy and a fluorescence spectroscopy.
>> Doctor Dana Sloan:So, boy, those are one word.
>> Debra Schindler:Yeah. What do we have to know about those?
>> Doctor Dana Sloan:for the patients listening here, when you have an endoscopy, some of that will be part and parcel of the diagnostic testing itself. So, for example, a patient who comes in with Barrett's esophagus, and we see a small nodule, within the Barrett's mucosa, we can go into what that means. M we might use chromoendoscopy in that setting if we're concerned about the possibility of malignancy, but from the patient's perspective, they're going to go to sleep, have the camera put down, have them gastroenterologists take a look and get their answers. We may use different kind of subtests, if you will, during the procedure to get a more, specific diagnosis.
>> Debra Schindler:What is Barrett's esophagus?
>> Doctor Dana Sloan:Doctor Monteith mentioned earlier that there's two kinds of, two types of esophageal cancer, one being the squamous type, which are out of the thin cells, and more, the upper esophagus. The lower esophageal cancers tend to be adenocarcinomas. Again, not exclusively, but most commonly, adenocarcinoma is typically something that will develop along kind of a disease pattern pathway of reflux related injury in the lower esophagus, leading to the precancerous condition of Barrett's, and then from there, developing in some patient dysplasia or precancerous changes that can then progress to cancer. So it's kind of a stepwise progression of, disease. So Barrett's esophagus is a change in the lining of the cells in the lower esophagus. Essentially. Since this has become such a widely recognized disease, I can say, tell our listeners that most, patients, the vast majority of patients who have Barrett esophagus, will never develop of esophageal cancer. In fact, since we started doing surveillance endoscopies for patients who have either short or longer segment Barrett's esophagus in the US, we've really have seen our ability to intercept these cancers at an earlier stage and potentially treat, again, not for everybody, but there is an opportunity there, doing surveillance or Barrett's esophagus to potentially catch esophageal cancers when they're just intramucosal, when they're very early stage and they're not causing these symptoms that we're discussing today.
>> Debra Schindler:And that is something that you would manage as a gastroenterologist, potentially.
>> Doctor Dana Sloan:So I don't, personally, I'm not an interventional gastroenterologist, but I have colleagues who are. And they can, yes, they can remove certain intramucosal carcinomas or cancers endoscopically without the need to employ doctor Monteith's expertise. So they, can actually go in and then with, a cap or what have you do an endoscopic mucosal resection and take the cancer out. Those are kind of more serendipitous findings. So that's not the patient who comes in with dysphagia or hoarseness. That's going to be the patient who maybe they had 20 years of reflux and they happen to be a smoker. And we do endoscopy and we kind of find those by accident, if I'm being honest.
>> Debra Schindler:Okay. You mentioned the treatments, surgery, chemo, radiation, not necessarily in particular order. But when it comes to surgery, how do you get to the cancer in an esophagus?
>> Doctor Duane Monteith:Yeah, so it's a lengthy surgery, because to get to the esophagus, you have to also get to the abdomen, which is going to be where the esophagus connects to the stomach. And the standard practice, esophageal surgery, meaning removing the part of the esophagus with the cancer, involves reconstructing the part that you took out of the esophagus by, using the stomach. So esophageal surgery, at the least, involves having to go into the abdomen, the chest, and sometimes, if the esophageal cancer is in the upper third, also having to go into the neck, all during the same procedure.
>> Debra Schindler:So this is not a minimally invasive surgery.
>> Doctor Duane Monteith:There are minimally invasive options. especially the, abdominal part, can typically be done minimally invasive. the abdominal part comprises what we call mobilizing the stomach or freeing it up and making what we call the neo esophagus, or making a tube out of the stomach, very similar to, sleeve gastrectomy, which is common bariatric procedure. Once the abdominal part is done, then we typically go into the chest and then actually mobilize the esophagus, dissect it from the surrounding structures, and then pull the, stomach up into the chest. So what we call a gastric pull up and then connecting everything back together.
>> Debra Schindler:And the stomach would function normally after that?
>> Doctor Duane Monteith:Somewhat normally.
>> Debra Schindler:What changes for the patient? What should they expect?
>> Doctor Duane Monteith:So very similar to patients that have had bariatric surgery. You're going to have to have smaller meals more frequently, because your stomach is going to be significantly reduced in size. You may have, just from the process of mobilizing the stomach, you can sometimes have gastroparesis, ah, which is the stomach not moving as or not contracting s while as it normally would. And that can lead to reflux. And so those are going to be the more common symptoms after surgery. But the stomach overall tolerates it very well.
>> Debra Schindler:What about absorption? Is there, are there any absorption issues?
>> Doctor Duane Monteith:Typically not, because the majority of absorption is done in the small bowels, which are not going to be affected, the surgery. And so it's really going to be how much you can eat before you're full.
>> Debra Schindler:And will the new esophagus have the same motility capabilities as before the cancer was removed?
>> Doctor Duane Monteith:Usually, yes. so, you know, one of the technical difficulties with forming a new esophagus is getting that kind of goldilocks zone of the right size, meaning you don't want it too narrow because then it's going to be hard for food to get down, but you don't want it too wide because then you're going to reflux a lot. So you have to kind of find that balance between just in the right size where, you know, you kind of minimize the reflux symptoms, but at the same time allows passage of the food, you know, without any obstruction.
>> Doctor Dana Sloan:I never heard that analogy. That's great. I've never heard it put that way. That's a great description.
>> Debra Schindler:I don't know if you just described this because you didn't use this language, but anyway, I wanted to ask about a minimally invasive esophagectomy. Is that what you're.
>> Doctor Duane Monteith:Yeah. So there are levels of minimally invasive esophagectomy, generally, if you're doing what we call three hole procedure, meaning for esophageal cancers, in the upper third of the esophagus, usually the neck part is not going to be minimally invasive. You just, there's no way around it. But there is.
>> Debra Schindler:Describe that. Are you going in from the front, like, this?
>> Doctor Duane Monteith:No, usually we go in through the left side of the neck because that's where the esophagus kind of runs closest to the surface. And once we've mobilized esophagus in the chest, pulled up the stomach into the chest, then we pull, pull the stomach up further into the neck, and then do our, what we call anastomosis, where we connect it back together. So that part of the procedure, the neck part, is generally never minimally invasive. The abdominal part, can be, we can do it laparoscopic, we can do it robotic assisted. The chest part can also be done either open, what's called a thoracotomy, or typically, what's done is, again, minimally invasive, either robotically or thoracoscopically or vats, which is another term that you may hear, which is just a fancy way of saying we go in through smaller incisions with a camera to do surgery that way, rather than the standard incision where we go between the ribs and kind of spread the ribs open to get into the chest, what's called the thoracotomy.
>> Debra Schindler:But you are a specialist of vets. Why would a patient not prefer that or go for the minimally invasive option?
>> Doctor Duane Monteith:Unfortunately, sometimes just based on the size, the location of the tumor, and the involvement, doing the open procedure, the non minimal invasive procedure is going to be the safer, the better surgery, because the goal of surgery is to not leave any cancer behind. because if you do, then it makes things a lot more difficult in terms of treating afterwards and the overall prognosis goes down significantly. so we always want to do the best surgery.
>> Debra Schindler:How would you know if you got it all? How can you tell?
>> Doctor Duane Monteith:Our pathologists will generally tell us, after the fact. There are tests that we do while we're in the operating room. Usually we want to make sure that what's called, that we have a good enough margin, meaning distance from the actual cancer. The pathologist will usually be able to give us a preliminary read in the operating room at the time.
>> Debra Schindler:What is vet's, an acronym for?
>> Doctor Duane Monteith:So it's, I hate the acronym. it's video assisted, thoracic surgery, or thoracoscopic surgery, meaning that it's. You've probably heard of laparoscopic surgery, which is the equivalent in the belly, or orthoscopic surgery, which is the equivalent in the joints. So VATS is, unfortunately an annoying acronym that's used for the same thing in the chest.
>> Debra Schindler:It's easy to remember, though, and if patients are going to go to their doctor and ask about it, at least they'll know what to ask for.
>> Doctor Duane Monteith:They can just say fats or minimally invasive.
>> Debra Schindler:Are there other surgical options or options in general?
>> Doctor Duane Monteith:So, as doctor Sloan mentioned, there are fringe cases where, if the cancer is caught very early, where you may not need the surgery, you can just have the lining of the inner lining of the esophagus where the cancer is removed endoscopically, meaning with the camera without any incisions so that's one option. There are ablation options, meaning anything from radiation to heat to cryoblastio. Yeah, freezing it, treating the cancer that way. But for the most part, the overwhelming majority of, esophageal cancer patients are going to need what we call multimodality therapy, some combination of chemotherapy, radiation and surgery. So for the earlier stages, except for the absolute late poor stage, which is stage four, meaning it is spread outside upside of the chest and to other organs, generally the mainstay of treatment is going to be chemotherapy and radiation. But for the rest, where there's no distance spread, then typically the treatment consists of chemotherapy and radiation upfront, what we call new adjuvant therapy, followed by, restaging, meaning looking to see how the cancer responded to that treatment. And as long as it has not progressed, then we go to surgery. And then typically again followed after surgery with more chemotherapy.
>> Debra Schindler:It sounds so textbook, like you guys really have it figured out now what the course should be. You were describing the ablation, that.
>> Doctor Duane Monteith:Is again, a, ah, rare use case, when generally patients are not a candidate for surgery, just because a lot of these other, technologies are really either for very early stage cancers, which are the rare ones that we see, or people that would not be able to tolerate surgery because of.
>> Debra Schindler:Their age or because of other health conditions.
>> Doctor Duane Monteith:Exactly.
>> Debra Schindler:And how do you guys come to that conclusion?
>> Doctor Duane Monteith:So that's part of the workup that we do, in the office, we will generally send our patient for a battery of tests, including tests to check out whether their lungs are strong enough, and tests to check out whether their heart is in good enough shape.
>> Debra Schindler:Okay, so what are some of the risks of esophageal cancer? Is there a hereditary component? Now I know you guys are not the genetic counselor, but what do you know about the risks?
>> Doctor Duane Monteith:Yeah, so the. I mean, I think the risk of any. If you have a family history of cancer, I think the risk, you know, if you have a family history of cancer, but there's really no, no clear link or any clear familial pathway towards, making you more likely to have cancer, esophageal cancer especially. So the risks are going to be, again, kind of the same that goes for everyone else. smoking, alcohol, not eating healthy, and then more specifically, again, reflux, gastroesophageal reflux.
>> Doctor Dana Sloan:There are rare disorders like tylosis, that can be associated with autosomal dominant familial patterns of esophageal cancer, but that's incredibly rare.
>> Debra Schindler:What is that, tylosis?
>> Doctor Dana Sloan:It's essentially, and please, I'm not a genetic expert by any means, but from my internal medicine boards years and years ago, thickening of the palms, the soles, I basically skin thickening. and for reasons that I don't understand very well, there's also a very, very high risk of esophageal cancer and those patients. But I can tell you, I've been doing this 20 years. I've never seen it. It was on my GI boards again, you know, decades ago, but it's incredibly uncommon.
>> Debra Schindler:Seems like such a weird connection that you have thickening of the palms, and then you may get esophageal cancer. I mean, that link just seems like such a stretch.
>> Doctor Dana Sloan:I'm sure there's, there's something more detail that I'm, you know, not well versed and understand, but doctor Montek, this right. You know, what patient, the modifiable risk factor. So the things that, you know, that your patients, our patients can do to lower their risk or to quit smoking. And frankly, I think that, the jury is still out on the risks of, cannabis smoking, especially in as much as cannabis and nicotine, can be linked, there can be nicotine contamination of cannabis. So I tell my patients, stop smoking everything if you can. Alcohol is certainly a risk factor, and so is obesity. I'm recognizing obesity is a clinical disease. We do know that that's a risk factor for adenocarcinoma in particular, so want our patients to try to get to a healthy weight.
>> Debra Schindler:Lori, what is, plummer Vinson syndrome?
>> Doctor Dana Sloan:So that's a condition that can be associated with formation of webs in the cervical, the upper esophagus, also commonly associated with iron deficiency, anemia, again, something that, I've seen once or twice over the years, still a very uncommon syndrome. While having those webs can be a risk factor for future development of esophageal cancer, not every patient with pulmonary incident will go on to develop that.
>> Debra Schindler:Lori. So other cancers are also a risk for esophageal cancer. Do you know which ones would lend themselves most to a, diagnosis of esophageal cancer?
>> Doctor Duane Monteith:So I think there's been a change in terms of how we kind of separate cancers, because in the past, it was very regimented. If it's in the esophagus, you have esophageal cancer, which is a different pathway of treatment versus gastric cancer, meaning cancer of the stomach, which was a different, again, treatment pathway. So now there's really the recognition that there's really some form of continuity, between the esophagus and the stomach. And so there's that category of gastroesophageal cancers. So a lot of those are kind of treated m more along the lines of, esophageal cancer versus, the pure gastric cancers. But again, it's kind of, when you think of it, it's really on a spectrum between esophagus and stomach.
>> Debra Schindler:If acid reflux leads to Gerd and Gerd leads to Barrett's esophagus, and Barrett's esophagus leads to esophageal cancer, is it feasible that medications for acid reflux will aid in the prevention of the cancer, such as, like melanta or tums, on a daily basis?
>> Doctor Dana Sloan:So not so much the over the counter antacids that are readily available on the shelves, but, we do know, we have studied chemo prevention in the sense of using proton pump inhibitors to lower, person's risk of esophageal acid exposure and therefore reduce their future risk of Barrett's progression, and esophageal cancer. So, yes, you know, our listeners, you know, if you have longstanding gastroesophageal reflux disease, your doctor may recommend a proton pump inhibitor, things like nexium and prilosecond, which are commonly, you know, understood terms. These medications are not themselves without risks. In terms of long term use, we know that patients who take long term PPIs may be at higher risk of things like bone loss, for example. But for patients who do have long standing GeRD and who have established Barrett esophagus in general, the benefits of long term PPI therapy do outweigh those risks. We'll, always use the minimum therapeutic dose. So, in other words, we won't use twice daily dosing if once daily dosing is sufficient to control a person's symptoms. But we do know that having a patient on the PPI can actually cause regression of Barrett's esophagus in some patients. So, these medications are impactful. There have been other studies looking at other medications for chemo prevention, like aspirin, but those haven't. I would say those aren't consistently being used. Again, the absolute risk of a person with bare esophagus developing esophageal cancer is still less than 0.5%. I mean, it's still a very, very low absolute risk. That number is still 30 times higher than someone without Barrett. So, you know, understanding if a person has Barrett's, and then doing the appropriate surveillance is still very relevant, very important, but it's still a very, very low absence.
>> Debra Schindler:Do you have any cases that might give people hope?
>> Doctor Dana Sloan:So I can say doing this for a long time, I've seen memorable cases at both ends of the emotional spectrum. You know, I certainly have had patients in their forties, you know, come in with dysphagia and, you know, are diagnosed with advanced stage esophageal cancer. but I have seen patients, again, with the kind of the serendipitous diagnosis, of an intramucosal, very early stage esophageal cancer, and they come in for, frankly, heartburn. You know, it's a very kind of innocuous symptom, but it's been longstanding heartburn. And maybe it's a person who's over age, you know, 40 or 50, who has a smoking history, and you have a compelling reason to do the endoscopy. Well, when you find, you know, a small, little nodule in that patient that turns out to be a malignancy, and you can get that patient to a cure, it's just, it's so rewarding, because, as doctor Monty mentioned, that does represent the minority of our patients. Most patients are going to be presenting at a much later stage. So it's always, you know, so wonderful for us to be able to catch these cancers when they are at these earlier stages.
>> Debra Schindler:In a late stage. Is it an option to remove a piece of the esophagus? can we live without that?
>> Doctor Duane Monteith:Absolutely, yes. So, I mean, that is a possibility, but generally, every esophagectomy is coupled with a reconstructive procedure. By far the most common is using the stomach again to form, what we call a neo oesophagus. There are a couple alternatives that are very rarely used. One is using a part of the colon as a, what we call an interposition, or meaning putting that part of the colon in the middle, between the stomach and the remaining esophagus. So a lot more complex surgery. And then there is the other alternative, which is, using a part of the small bowel to make that connection. There's been, you know, for decades, thoughts of using an art, a synthetic material, to replace the esophagus. However, those have never panned out.
>> Debra Schindler:Can't get something to match or mimic the esophagus.
>> Doctor Duane Monteith:Right, exactly.
>> Debra Schindler:Is that the best part of your work? I mean, do you like, do you enjoy the reconstructions?
>> Doctor Duane Monteith:Yeah, I mean, I think when you're able to do it, I mean, I think with the increased use of, the proton pump inhibitors, we are seeing fewer esophageal cancers. When you look at the overall national and international trends, I mean, there's a slight decrease in the incidence of esophageal cancer, but we've certainly seen it on the surgical, end, and I think with these cancers getting diagnosed earlier. And also there's like, doctor Sloan mentioned the chemo prevention in these patients with Barrett's esophagus that may have gone on to develop esophageal, cancer. We're seeing fewer of those, which I think makes me very happy. If I didn't have to do another esophagectomy, I would be very happy.
>> Debra Schindler:You two really do work together with these patients, the esophageal patients, in getting them to a, successful result. Are there other members of the team?
>> Doctor Duane Monteith:Yes. So, the other parts of the team are going to be the, medical oncologists, who are the doctors that would be giving chemotherapy. And also one of the more recent advances in cancer treatment, including esophageal, is immunotherapy. So, the medical oncologist would be the ones, deciding what and how long a patient would be getting those kinds of treatments. And then the other important part of the team is the radiation oncologist, doctors that use, radiation to treat the cancers, and they're a very integral part of, treating esophageal cancer. And then, you know, also, we can't neglect the other specialists, everything from nutritionists, because you have to optimize patient's nutrition before undergoing a, major surgery like an esophagectomy. And then also just our oncology social workers that we have here at Franklin Square, that kind of look at the other kinds of things that may affect patients treatment, everything from socioeconomic issues to just things like depression. And so we have a lot of resources for our esophageal cancer and cancer patients in general available through the MedStar Georgetown Cancer Institute at Franklin Square.
>> Debra Schindler:What's the biggest concern that you get in terms of patients with a new diagnosis coming in and having questions? What do you think their biggest concern is?
>> Doctor Duane Monteith:The biggest concern is always, do I have to start writing my will? And, unfortunately, no one can predict how long you're going to live, how long you're going to survive after a, cancer diagnosis, especially esophageal cancer diagnosis. The numbers don't look great. but I think everyone is different. We have seen early stage esophageal cancers that unfortunately don't make it a year. We've seen stage four esophageal cancers that have lived five years and beyond. I mean, that is always the main question. And then also, you know, I think the other concern, again, is quality of life. You know, we wouldn't be doing esophagectomies, we wouldn't be doing all these treatments if we didn't think you were going to have a reasonable quality of life after the treatment. But again, that's always a, huge concern.
>> Debra Schindler:What's your best advice at this point now? And do you hope people listening to this podcast will take away from it.
>> Doctor Dana Sloan:Knowing that there are things that are out of anyone's control? I'd say, you know, control the things that you can and modify, those risk factors that you can. So, cutting back, reducing smoking as much as you possibly can, cutting back or eliminating alcohol as much as you possibly can, and working with your primary care team in terms of achieving a healthy weight, we know that these are all factors that can contribute to one's risk, for esophageal cancer, along with other cancers, frankly. and, if you can modify, or eliminate those risk factors, it, goes a very long way into keeping you out of both of our offices, because, again, this is never a diagnosis that we want to make. Secondarily, though, I would say, you know, if you do have longstanding reflux or heartburn, or you're getting new symptoms, new trouble with your swallowing, food, getting stuck pills, getting stuck, change, in your voice, don't ignore those symptoms. This is not a hopeless diagnosis. And the earlier we can get you evaluated and get you a diagnosis, even if it's something other than esophageal cancer, the better off you'll be.
>> Debra Schindler:True or false. Hiccups are a sign.
>> Doctor Dana Sloan:It can be a late sign, especially if a nerve, adjacent to the esophagus is being tickled.
>> Debra Schindler:Amazing. Thank you. Thank you both for what you do, for caring for patients, and for sharing your wisdom with us on MedStar health doc talk.
>> Doctor Dana Sloan:Thank you for having us.
>> Doctor Duane Monteith:Yep, thank you.
>> Debra Schindler:To learn more about risk factors, symptoms, detection and treatment of esophageal cancer, go to medstarhealth.org backslash services. Esophageal cancer. That's esophagus. Ah, cancer.