(bright music) - [Announcer] The region's premier medical information program, Call the Doctor.

- Esophageal cancer is a rare, but often devastating illness.

The National Foundation for Cancer Research estimates that although someone's risk of developing the disease in a lifetime is only 0.5%, the five year survival rate averages just about 20%.

And because symptoms usually don't appear until it's advanced, esophageal cancer can be difficult to treat.

We discuss issues with the esophagus and what acid reflux disease and a syndrome called Barrett's esophagus have to do with it.

That's now on Call the Doctor And hello and welcome to this episode of Call the Doctor.

I'm Julie Sidoni, I'm the News Director here at WVIA, and I'll be the moderator for the show this season.

In this episode, we're gonna be discussing the esophagus, not typically a body part we hear much about, but the esophagus plays an important role in our overall health and certainly problems can develop.

We have Dr. Thomas Churilla with us right now from Northeast Radiation Oncology Centers.

You've been here once before, Call the Doctor this season, we're really happy to have you back, Dr Churilla.

- She thanks for having me, Julie.

- All right, so I mean, we were...

I mean, I don't wanna say joking about it, but the esophagus, it's just one of those things you don't hear about very much but it plays a really important role in our digestion, in our systems, explain a little bit more about what it is and what it does.

- Yeah, it's a good point.

Kinda think of it like an unsung hero.

We eat, we swallow, we don't think about those actions very much, but I like to think of the esophagus as this muscular tube.

It's roughly about 40 centimeters long or a little less than 20 inches long.

And it's this muscular tube that carries food from our mouth to our stomach.

So it's pretty much a layer of epithelium.

So it has this lining, it has this muscular layer and then this connective tissue layer beyond it and its major function is to help transport food to the stomach.

So it contracts in a very regular fashion, taking a bolus of food from our mouth down into our stomach, then that's the first part of digestion, essentially.

- So it starts sort of right here in the back of your throat, roughly.

- [Thomas] Yeah.

- And goes right into the stomach.

- Yeah, exactly.

So pretty much the back of the throat or the pharynx goes into a muscle, this thick muscle, and that's pretty much the start of the esophagus, the cricopharyngeus.

And then it's this long band of longitudinal muscle and it connects to the stomach at the GE junction or the gastroesophageal junction.

- And when it's functioning normally, don't even know it's there.

- Don't even know it's there.

- What are some of the first issues that you might start to notice if there is a problem, and I'm not even really speaking cancer necessarily, but if there's an issue with your esophagus, what are some of the first symptoms that a patient might notice?

- Yeah, so mostly trouble swallowing and weight loss.

They can be the two cardinal things I think of, for both cancer and non-cancer related causes.

So if the esophagus is irritated, whether it's by tumor or some other process, say as simple as gastroesophageal reflux disease or GERD, you can have trouble swallowing, you can have burning with swallowing, a sense of upset stomach, what we call dyspepsia, reflux type symptoms, burning that seems to travel up the chest.

So pain with swallowing, reflux type symptoms.

And if it's a more serious problem, such as an esophageal cancer, if you have a mass in the esophagus that can lead to obstructive symptoms.

So you might notice that there's some difficulty swallowing foods, certain types of textures, maybe more solid textures can be more difficult going on.

Food feels like it's getting stuck somewhere in the chest or the throat area.

So really, it's weight loss because of that problem swallowing, sense of food getting stuck, they would be the cardinal symptoms that there could be a serious problem with the esophagus.

- Are those symptoms that will just sort of continue as they are, will they get very quickly worse or is that a way case by case basis?

- Really a case by case basis.

But typically it could be a more gradual onset, maybe just a little bit of upset stomach or a little bit of difficulty swallowing to start.

And then if it is an underlying say, cancer or neoplasm, it might grow to where it becomes more and more obstructive.

So maybe more foods now are becoming more difficult.

So maybe softer foods are becoming more difficult to swallow.

So if it is due to an underlying say cancer, we would typically expect a slow progression where maybe, people are minimally symptomatic when the tumor is small or not really having any symptoms when the tumor's small.

And then as the tumor got bigger, it would lead to more of those obstructive symptoms like the trouble swallowing and the weight loss that we talked about.

- So let's talk a little bit about acid reflux, which is quite common and lots of people deal with it and take over the counter medications.

First, let's talk about how you can know whether you have acid reflux and second, when a minor case might then turn into something that needs to be watched or monitored a little more closely.

- Yeah, so reflux certainly is a very common problem.

Our gastroenterology colleagues certainly see this problem frequently and our primary care colleagues.

So it is very common, but the cardinal symptoms again are more so a sense of burning, could have a sense of upset, sometimes even symptoms that aren't very obvious, like a nighttime cough can be symptoms of irritation in the esophagus.

- Nighttime.

- Yep, nighttime cough.

So because you're lying flat, the stomach acid can kinda travel along the esophagus and exacerbate that and can lead to a cough sensation.

So yeah, so some symptoms that might not be obvious actually could be a sign of underlying GERD or gastroesophageal reflux disease.

So I always recommend if patients are experiencing that talk with their primary, there's certain red flag symptoms, that might prompt more intensive investigations.

So such as, reflux symptoms that are progressive, symptoms such as weight loss, any type of difficulty passing food or trouble swallowing, certainly family history of esophageal problems or cancers would be another red flag that might prompt evaluation to a gastroenterologist and maybe even consideration of a scope to make sure there's not an underlying problem.

- Is there a higher risk factor with esophageal cancer when there's other issues happening for...

I mean, I know the stomach is all kind of connected, would there be higher risk factor if say there's something happening in your liver, your stomach, et cetera.

- Yeah, so I think the major risk factors for esophageal cancer would be smoking, alcohol, acid reflux and obesity.

So of the two major types of esophagus cancers, there's squamous cell cancers and adenocarcinoma.

So the squamous cell carcinomas used to be more common now they're a bit less common.

But they're typically, the major risk factors are irritants of the esophagus, such as alcohol and tobacco or cigarette smoking.

What we're seeing more of is really a shift towards more is more of these adenocarcinoma or tumors of gland cells.

And those are the ones that are really more associated with reflux symptoms and obesity.

So we think... And it's something that we don't fully understand, but we think that one of the mechanisms that the esophagus tries to deal with stomach acid is to make these little glandular cells kind of turn into more stomach lining to help protect itself from the acid that's going into the esophagus, and that's a condition called Barrett's esophagus.

Again, our gastroenterology colleagues can kind of go into detail about that and how that's monitored and assessed for.

But that could be a precursor to esophagus cancer.

So you have these cellular changes that kind of protect against the esophagus against the acid, but then that could be a precursor an esophagus cancer.

And these are typically cancers that develop in the lower part of the esophagus where the esophagus connects to the stomach or the GE junction.

- So those risk factors, again, smoking, alcohol, the other two you said.

- Reflux and obesity.

- Reflux and obesity.

The reason that got my attention is because those are sort of the same symptoms you hear for a lot of issues that people will find.

It seems like it's all very much connected.

- Yes, yes it is.

And you think about it, it's some sort of insult to the esophagus that's leading to these changes that may predispose one to a cancer.

So tobacco and alcohol have their irritants, their cellular irritants.

So they can lead to damage at the DNA level that can turn into a tumor.

Likewise stomach acid irritating the esophagus can lead to those dysplastic changes or those changes, those pre-cancer changes that we talked about.

So they all kinda share this common thread where there irritants of the esophagus that could predispose one to developing a tumor.

- So by the time someone gets to you, it has been determined that they have cancer in some way, shape or form.

Can you explain a little bit how you would treat esophageal cancer, whether that's different from other types of cancers.

What are the things you have to particularly look for in those cases?

- Yeah, it's a really good question.

So like any other type of cancer the first, most important thing is really confirming the diagnosis.

So usually patients by the time they see us as oncologists will have had a biopsy and probably some imaging studies by then.

So the biopsy's important because if you see a mass in the esophagus, say someone's having symptoms that prompts an evaluation, they might get an endoscopy or a scope that goes down the esophagus to look, a doctor might find a mass.

So the next most important thing is biopsying that mass to see if it indeed is a cancer and if so what type.

We alluded to before, there's two major types of esophagus cancers, squamous cell carcinomas and adenocarcinomas.

Squamous cell carcinoma just means it starts on the outer lining of the esophagus, whereas an adenocarcinoma starts from the glandular cells and they behave a little bit differently.

They're treated oftentimes in a similar fashion, but they could behave a little bit differently and we do think about them a little bit differently.

So the histology or the type of cancer it is matters.

And then after a biopsy confirms that there's an esophagus cancer, the next most important thing is determining how big it is or what is the stage.

And there's three major things that we look at.

So number one is really how big the tumor is.

Number two is whether or not there's any lymph nodes involved.

And number three is whether there's any evidence of spread or distant metastatic spread beyond the esophagus.

And there's different studies that we do to help determine the TNM stage.

So for instance, our gastroenterology colleagues will do a scope and they can do what's called an EUS to get a very accurate sense for how deep the tumor grows into the esophagus.

So some tumors, we stage them by how long, how wide or how big they are.

Esophagus cancers that seems to matter more, how deep into the esophagus they go, that's what T staging is.

So if they're very superficial, it's what we call a T1.

If they poke into the muscle, that's a T2.

If they're through the muscle, into the connective tissue, that's a T3 or more advanced lesion.

And if it's beyond the connective tissue into another organ, that's a T4.

Likewise the endoscopy can tell whether or not there's any lymph nodes in the esophagus area that might signify some regional spread, and then oftentimes we'll do CAT scans and/or a PET CT to do a whole body survey to see if there's any evidence of spread beyond the esophagus.

- Before we get to how else this is treated, just make sure people understand the scope, the endoscopy scope.

You can tell all of that by that one scope?

- Yeah.

So the two major things the scope can tell are, how deep into the esophagus the cancer is or the T stage and it's also very good for seeing whether or not there's any lymph node spread.

So for instance, one might do a CAT scan and you don't really appreciate any lymph nodes, and the EUS or the scope when they go in, they can do a very detailed look of the lymph nodes around the esophagus and sometimes see very small but abnormal appearing lymph nodes that are presumably involved with cancer.

So an EUS can be a very important way to see if there's any lymph nodes that might not be apparent on another study.

- [Julie] I gotcha you.

- For distance, spread, really CAT scans and PET scans are more accurate to see because it's beyond the esophagus.

So you need really a whole body type of survey.

- Is radiation often suggested as one of the treatments for esophageal cancer?

- Yeah.

So radiation has a very important role and it depends mostly on the stage.

So there's kinda three broad groups.

So one would be a small very early stage tumor, one would be a bigger tumor that's confined to the esophagus with or without lymph nodes involved.

And then the final group would be one that has spread beyond the esophagus.

So for the very early stage cancers, oftentimes they can be managed with either resection through the scope or surgically alone.

The problem is by the time esophagus cancers cause symptoms, they're usually beyond those very small stages that can be cured easily with scopes or surgeries.

So the more often thing is that, if patients present with symptoms, they're usually a bit deeper into the esophageal wall, have lymph node spread or worse, if they're beyond the esophagus.

For those cancers that are limited to the esophagus, but that are larger poking through the wall or lymph nodes involved, typically radiation has a very important role in combination with chemotherapy to shrink them down and prepare someone for surgery.

Sometimes people might be too sick or they can't tolerate the surgery or the surgeon may say that it's unable to be removed.

And then radiation and chemotherapy can be used to try to cure cancer.

And then finally, if a cancer has spread and it's no longer curable, but it's still causing symptoms in the esophagus, radiation's a very effective treatment that can be used to shrink the tumor and help alleviate symptoms or palliate symptoms such as problems swallowing, pain, bleeding, that sort of thing.

- And what kind of issues or perhaps side effects or symptoms might people have from being treated for esophageal cancer.

- So in terms of the radiation...

So radiation is painless x-rays targeted at the esophagus.

And typically, although patients don't feel anything on treatment, as you go through treatment, could have some side effects related to the radiation, and they're all really localized to the esophagus area.

So fatigue is one thing, patients tend to feel more tired on treatment.

Could have irritation of the esophagus because the esophagus lining can get irritated from the radiation and oftentimes people might tell me, "Doc, I'm swallowing a little bit easier, "but I'm starting to have "some more pain now with swallowing."

And we can very effectively manage that with simple medicines, either over their counter or prescription.

And some minor skin reaction, it's usually nothing to write home about, people don't get severe radiation burns, but could have some dry peeling skin.

So they're the big things that I think of on treatment, we think of those things getting better.

There are some things that could crop up later on down the road.

The two big ones I worry about are, radiation's effect on the heart and the lungs.

Radiation can increase the risk for heart disease, it can cause some lung problems, but we have very more sophisticated techniques to help really even the radiation, the esophagus tumor, really drive it away from the lungs and the heart to help mitigate those risks.

- It seems kind of...

I mean, not that any cancer isn't scary, but it seems like a scary proposition to think that by the time you feel or notice any sort of symptom, it might be a bigger tumor, a larger tumor, not that it isn't able to be treated.

Is there anything people can look for or, because the scope... What I'm getting at is a scope is not one of those recommended checkups, correct?

- Correct.

Yeah, it's not like a mammogram or a colonoscopy.

I think part of the problem is esophagus cancers are rarer cancers.

If you think about how many are diagnosed in the United States, it's only about 20,000 a year, which roughly is about 1% of all cancers in the US.

So it's a relatively uncommon cancer.

And then again, the other problem is that, by the time it becomes apparent or people have symptoms from it, they're usually at a more advanced stage, but I think their red flags to look out for, really those reflux symptoms that are persistent.

I usually recommend people talk with their primary care, see whether or not maybe they should be evaluated by a gastroenterologist, if they really have a longstanding history of reflux symptoms.

And then of course any type of problem swallowing.

If there's any type of problems with food passing through the esophagus, into the stomach, any type of sensation of food getting stuck, certainly any type of bleeding, whether people are bringing up blood or passing blood or dark stool, they would be certainly some red flags that there might be something more than simple GERD.

- And now we also wanted to get a different perspective or perspectives from a gastroenterologist.

And I'm very happy to introduce Dr. Aman Ali, who's joining us from Commonwealth Health.

Dr. Ali, can you hear me all right.

- I can hear you well.

- Fantastic.

- Thank you.

- Thank you so much for being here to help us wade through this.

So Dr. Churilla had helped us out a little bit with what the esophagus is and how it's treated when it gets to those very dangerous cancerous issues, but there's a whole lot that goes on before we get to that point.

And I know that's what you and I kinda wanted to flesh out a little bit.

First, let's talk about some of the risk factors you might look for.

Before we even talk about cancer, what are some of the things that you might check someone's esophagus for?

- Patients who do have chronic acid reflux, even if it is controlled on over the counter medications.

In particular, if they are above 45 years of age, if they have other risk factors such as if they smoke or if they have obesity or they're overweight, that would trigger some of the concerns about endoscopy.

Patients who have had family history of esophageal cancer, such as in first degree relatives and who have chronic indigestion type symptoms.

These are the patients who we look for, and if they have some lab abnormalities such as anemia or low blood counts, that also raises our concern.

If they have unclear reason for weight loss, and then that should also trigger an alarm.

- So acid reflux is fairly common from what I understand.

When do you know whether acid reflux once in a while is an okay thing, or when it gets into problematic territory?

- That's a great question.

So once in a while, if one over eats or they eat certain kind of foods, which are either spicy, greasy, foods that that can cause a little bit of indigestion and acid reflux.

But what is more important is if it is more frequent and let's say, if it's more than three times a week, you're reaching for that over the counter anti-acid, at least three times a week, and/or if you have those symptoms and some of the abnormalities I discussed earlier if you have those present, then that definitely is a concerning thing.

It's also very important to point out that a lot of patients have what we call silent reflux, which means they don't really have any symptoms and their risk factors may be just a high weight or overweight person, or if they have other comorbidities associated and they may continue to have underlying gastroesophageal reflux, which leads to Barrett's esophagus, and eventually to cancer.

- Barrett's esophagus was gonna be my next question.

Does acid reflux turn into Barrett's esophagus, or is it an entirely separate issue that you see sometimes?

- It is a spectrum.

So a lot of time, if it's acid reflux is undetected or not treated, it will continue to progress and select percentage of patients where they have other risk factors mentioned before, it will turn into a Barrett's esophagus.

Now, Barrett's esophagus is nothing but basically change in the lining of the esophagus.

Esophagus is lined by a normal squamous epithelium, that's how God made us.

But over time, when as acid continues to bed the lower end of the esophagus, it kind of sort of adapts to this new acidic environment in the lower esophagus and the lining of esophagus turns into lining of stomach.

It's almost like an evolutionary sort of a response for esophagus to adapt to this excessive acid.

And when that transition happens, that's what called Barrett's esophagus.

We can see it on the scope when we evaluate the patient and we can confirm it on a biopsy.

- Can it be reversed in any way, or once you have Barrett's, that's just something you have to be monitored for so that it doesn't get any worse.

- So it needs to be monitored.

Once a diagnosis of Barrett's is made, you should be vigilant and it does regress with the good lifestyle modifications, appropriate treatment, but still, I think monitoring is important.

- Once you've figured out that someone has Barrett's esophagus, then what?

What's the monitoring like to make sure that it doesn't progress into a cancerous situation?

- So the current guidelines is when we first make the diagnosis, we go back usually in one year to do another endoscopy, which is basically a simple camera test, takes about five minutes to perform it and you're sleeping through the test.

Very, very simple, easy to do test.

So Barrett's esophagus is diagnosed, not by any x-rays or any other noninvasive means, but you need to have what EGD or gastroscopy or endoscopy.

Once you first diagnose it, then you go back in one year to reconfirm the diagnosis.

And you're looking for concerning cells in there, we call them dysplasia.

If you don't have dysplasia, then you go back every two to three years afterwards to have a routine surveillance endoscopy.

But if you do find dysplasia, depending on whether it's a high grade or a low grade dysplasia, then the treatment is different and that's actually a step closer to cancer.

So you have to be adapting a completely different treatment paradigm for that.

- And what about GERD, hat's a term I've heard quite a bit, but I'm not sure where that falls in there in the risk factor territory there.

- So GERD is gastroesophageal reflux disease, and it remains untreated over time in patients who have other risk factors.

It will turn into Barrett's esophagus and then eventually into the dysplastic Barrett's, such as low grade or high grade dysplastic or dysplasia, carrying Barrett's And that's essentially a blink away from turning into a very early esophageal cancer.

- Is there something that people can do if they're of normal risk or not a higher risk, no family history, for instance, is there something that people can do to perhaps try to prevent these problems from happening?

- So we should not ignore even a minor continuous ongoing reflux, especially in patients who are above 45 years of age.

We have seen Barrett's esophagus, unfortunately in very young people as well.

I have patients who are in their twenties, they have it too?

So not only age, but also ongoing symptoms are important.

Unfortunately, we will not be able to catch patients who have silent Barrett's or silent acid reflux disease.

Current guidelines, don't let us screen patients who don't have any symptoms.

But the patients who do have ongoing symptoms is important that we should monitor them, or first diagnose and then monitor them.

I do want to point out that there is many roadblocks in the evolution of cancer.

So first, if you diagnose gastroesophageal reflux disease appropriately treated and monitor it.

If you diagnose Barrett's, then you follow the guidelines.

I do take pride in providing these roadblocks.

We brought a lot of new techniques in the (indistinct) county over the last five to seven years, which basically did not exist before.

So if we see this dysplastic Barrett's, we do resection of that, just with the scope without requiring a big invasive surgery called endoscopic menopausal resection.

We performed that and essentially cut out the seed of the cancer even if it fully involves the lining of the esophagus and all the muscles of the esophagus.

So essentially just nipping it in the butt, and then we have ablation treatments as well, much like a dermatologist will freeze off a suspicious mold or something of that nature.

We can do that same exact thing endoscopically to burn off or freeze off the area of esophagus which is of concern, hence preventing them to go into that dreaded cancer stage, which is unfortunately still has very high mortality state at this point.

- All right.

Dr. Aman Ali, joining us from Commonwealth Health, we really thank you for your perspective doctor.

- All right.

I'm very happy to be there.

- So what about any sort of advancements that you have seen in the last couple of years or where you think treatment is going?

- Yeah, that's a good question, Julie.

So I think over the past decade, our techniques have gotten a lot better in terms of radiation therapy, the ability to deliver very accurate radiation therapy to really hone in on the area that we wanna treat, drive radiation away from things that might cause people side effects.

I think that's we've made tremendous progress in that.

I think there's a lot of exciting advancements being made, a lot of exciting studies in the pipeline, figuring out ways that we can more optimally use radiation in combination with chemotherapy to help shrink these tumors and prepare patients for surgery.

There's been a lot of interesting work in immunotherapies, and I think that we're gonna see an increasing role in using immunotherapies or priming our immune systems to help fight esophagus cancers as well.

So I think there's a lot to look forward to in the coming years in terms of how we can help patients the most with esophagus cancer.

- Think of it almost as preventable.

I mean, hopefully down the line, it might be where it headed.

- Yep, absolutely.

- Yeah.

All right, Dr. Churilla, thank you so much for your time, we always appreciate it.

That will do it for this episode of Call the Doctor.

And if you've missed a portion of the show, you can find it at our website, wvia.org, there you'll also find a schedule of when the show will be rebroadcast.

You can also find us of course, on the WVIA mobile app.

Thanks again for being here.

I'm Julie Sidoni and for all of us here at WVIA, we'll see you next time.

(bright music)