J.L. WEBB

Viewed in tandem and without context, the two statistics are alarming.

* In the past quarter-century, the incidence of esophageal cancer has increased 350 percent, faster than any other malignancy in the western world.

* The 5-year mortality rate for patients diagnosed with esophageal cancer is 90 percent.

Yet, there is more hope than ever that the disease is treatable if it can be detected early, which is why medical specialists are placing a much higher priority on identifying who is susceptible and why.

And there are encouraging signs that approach is sound.

When esophageal cancer is caught before it has metastasized or spread to other organs or the lymph nodes, “there is about a 90 percent chance of a 5-year survival, which is extremely good,’’ according to Dr. Scott Kelley, surgical oncologist at H. Lee Moffitt Cancer Center & Research Institute in Tampa.

As section head of esophageal oncology and surgery as Moffitt, Kelley, 41, is deeply involved is establishing an early detection program for a cancer that has risen dramatically along with the rates of obesity and acid reflux disease.

“Twenty-five years ago, the most common type of cancer of the esophagus was the squamous cell type, for which the risk factors were heavy drinking and smoking,’’ Kelley said. “But times have changed and now the adenocarcinoma has taken over incredibly. It’s really become almost an epidemic.’’

Most of the 14,000 Americans diagnosed with esophageal cancer last year have adenocarcinoma “and the cause is not the old factors of drinking and smoking,’’ Kelley said. “It’s the reflux of acid contents from the stomach to the lower esophagus.’’ That constant acid “bath’’ changes the cells that line the esophagus from normal squamous to intestinal metaplasia, or Barrett’s esophagus, he said.
Ninety to 95 percent of those who have Barrett’s esophagus never develop esophageal cancer. But Kelley and other researchers are trying to discern why some Barrett’s patients progress to low-grade displasia, then to high-grade displasia, and then to esophageal cancer. “We really don’t know who is going to progress, or why, but we have to assume that is has something to do with the genetics,’’ which is what his research focuses on.

“I look at some of the genetic changes that take place within the cells. There has to be something different. Not all Barrett’s is necessarily the same, and it may be that there are certain genetics that predispose (patients) who go from regular epidilium to Barrett’s to cancer, because most people don’t progress,’’ Kelley said.

The biggest obstacle to that research, Kelley said, is that “we don’t really know how prevalent it is in the general population because in this country. we don’t screen for esophageal cancer the way we do colon cancer,’’ for which the recommendation is that everyone who turns 50 undergoes a lower endoscopy.

“I want to change the way we look at esophageal cancer,’’ Kelley said emphatically. “I would like to screen everyone who has reflux disease … because somewhere between 5 and 15 percent of these 60 million Americans who experience heartburn on a monthly basis are going to have Barrett’s. We just don’t know who of those 5 to 15 percent are going to progress to cancer.’’

Dr. Omar Kayaleh, section chief of gastrointestinal oncology at the M.D. Anderson Cancer Center in Orlando, shares Kelley’s frustration with not having adequate methods to identify which patients are at risk.

“The data is really slow in coming,’’ Kayaleh said. “Even if you have Barrett’s esophagus, the chances of it developing into a malignancy is somewhere around one-half to 1 percent. So, if you’re going to have a study to see whether there is any impact to what we do, it’s going to have to be huge. And recruiting that many patients for (such a comprehensive study) is very hard,’’ he said.

Although physicians are working diligently to detect esophageal cancer early, they often do not. That is because, Kelley explained, “The first symptom people pay attention to is when food gets stuck in their lower esophagus. Unfortunately, that usually means the tumor is big enough to partially obliterate the lumen of the esophagus. By that time, things are pretty progressed.’

Kayaleh, 48, said that both types of esophageal cancer are treated the same, depending on the stage of the disease.

“We do an endoscopic ultrasound to confirm and look at the depths of invasion in the region,’’ he said. Many times, esophageal cancer spreads to the liver and is diagnosed at Stage T2. The protocol is chemotherapy and radiation, he said, and after a few months, possibly surgery. “But there is controversy about how much surgery adds to the equation (when the cancer has spread). It can prevent local recurrences after chemo and radiation, however, it does not prolong overall survival. It often comes back,’’ Kayaleh said, noting that of the approximately 15,000 Americans who were diagnosed with esophageal cancer last year, almost 14,000 died.

But if the cancer is “confined to their esophagus, it is still a very treatable condition,’’ Kelley noted. “We give them upfront chemotherapy and radiation, and six weeks later, I take out their esophagus, form their stomach into a tube and bring it up to the top of their chest,’’ he said.

The surgery is a minimally invasive esophagectomy, and Kelley was one of the first surgeons in the nation to perform it laparoscopically. He has done more than 100 of the surgeries, which takes 3 to 4 hours each. “There is minimal blood loss, they get out of the hospital in about seven days and they go home eating regular food.’’

But, Kelley and Kayaleh agree, early detection is key to any meaningful treatment of esophageal cancer, and more scientific emphasis needs to be placed on understanding who is likely to acquire the often fatal disease.

“It’s all about detection,’’ Kelley said. “It makes perfect sense to me that when a person goes in for a colonoscopy around age 50, that they undergo an upper endoscopy at the same time. Then we can identify people who have Barrett’s and get a handle on things at an earlier stage.’’



March 2008